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WELL/PUMP PERMIT <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> (' 1 CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;�^ Y <br /> JOB ADDRESS -1�J105% JM PiL I CITY/ZIP U Z y <br /> clIfrle u�J -V9� > <br /> CRO35 STREET YY ( �I Ay�Py{.N�1 {nl PAp�R1{C�AE/L�SIZE LAND USE APPLICATION# S <br /> OWNER NAME A4�/�/� C I�1 V E t/1 t, —� y ' `t f I' V (�PHONE <br /> OWNER ADDRESS { J I.] D CrTY/STATE21P <br /> CONTRACTOR PHONE <br /> �r`'- V 1 ZZ _ <br /> CONTRACTOR ADDRESS I f CrTY/STATEZP 10 ,V• 'J � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/71P �} <br /> LICENSEylC 57 D C-61 ;;D-09 I;Other NUMBER �� EXPIRATION DATE 0-130'U✓I <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)r_Arsenic(4393) <br /> INTENDED USE [:Domestic/Private rrigation/Agncultural Industrial "Water Quality Monitoring U Soil Sampling/Characterization <br /> C Public Water System <br /> — <br /> If different Irwn Owner Water System Name Corflxl Name or Phme Num°er A <br /> TYPE OF WORK _ ew Well ,-: Replacement Well �l Well Alteration/Modification 0 Other <br /> Monitoring Well(s) _#of wells LlSoil Boring(s) a of D°A gs C Geotechnical s or lwnnpa <br /> I' Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair D <br /> New Pump 0 Pump Replacement fl Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> S� `/^02 <br /> Drilling Method s/Mud Rota U Air Rotary I'Auger <br /> n Cable Tool i;Push Point C Other 411, 0 <br /> Proposed Well Depth tt Excavation !V In diameter Open Bottom G Gravel Pack/Gravel Size-* in di Q <br /> I Conductor Casing in diameter / Conductor Casing Depth R NEALT/ ON ENT UNT y <br /> Well Casing Diameter I L in Thickness/Gauge/ASTM Sched� :'Steel lasbc Stainless Steel ❑Other E 7-R L <br /> Grout Seal Depth�_ft '7 Neat Cement(94 Ib bag/5-10 gat water) U Sand Cement sack mix/7 gal water ENT <br /> Wfentonite(20%solids) 'I Other <br /> Grout Placement Method EKumped G Free Fall G Other L:Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 77 Pump Contractor E Other <br /> 0 Concrete Pedestal❑Dimensions:Width R Length R Thick in U Christy Box Stove Pipe <br /> PUMP .1 SubmersibleC Turbine C Other HP Pump Set R Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINc7LIJ=�VANCE NOTICE REQUIRED FQ}R�IN�SPUE�CTJO�NS-Pp kASE CALL(209)9/�5,3-7697 UW^n <br /> SIGNED \\11��11��lilt TITLE✓n1 'I I/�(ITT�� L I� LL' O'V. )'. !�U l/✓ <br /> DATE_ <br /> I T-71 <br /> htbeP <br /> FF <br /> DEPARTMENT USE ONLY <br /> Area Ce 11 <br /> Application Accepted By <--_ Date �3 d V q `l <br /> I r Employee ID# <br /> Grout Inspection By , ti/� _ Date q 2AJ? 1-W ❑ SPECIAL WBII Permit <br /> Pump Inspection By Date ❑ WAIVER Received n <br /> Soil Boring Inspection By Date _ Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Chad* Amount Permit/ <br /> Codes Info .Cash Remitted Data Service Re uest# Invoice# Well ID# <br /> EHD 41-08 9!01118 <br /> WELL/PUMP PERMIT <br />