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f <br /> an. q���20� C-&r //3 522.ZV AlG - a pg✓,4 /Cj�1 e 0 -4,77 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)466.3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd FXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRES :. 6 CITYZP m <br /> �!1 IJ �'1L �Ai D <br /> CROSS STREET f I APN ' y _ YARCEL SIZEf•-.G'I SE APPLICATION# o <br /> OWNER NAME (Xyj�e. O PONE u <br /> OWNER ADDRESS U Y Sill• • CITY/STATEIZIP <br /> CONTRACTOR rT L10 PHONEI • I <br /> Al <br /> CONTRACTOR ADORES CITY/STATEZP V / <br /> SUBCONTRACTOR/CONSULTANT PHHOON 2bl-1e1034 <br /> SUBCONTRACTOR/CONSULTANT ADDRE99 ITVi(.�TATE/11P Y <br /> LICENSE �/C-57 C-61 D-09 Other NUMBER U -1/ rANr/jam `/re;IRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUB CO NT RACTO RR//ICI NS LT l <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) ._Arsenic(4393) <br /> INTENDED USE Domestic/Privale Irrigalion/Agricultural - Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Nater System <br /> If different from Owner: Water System Name Contract Name or Phone Number <br /> TYPE OF WORK New Well - Replacement Well i ll Afteration/M tion Other <br /> Monitoring Well(s) #of well 1- 1 Boring(s) a°f b0""9e �,eotechnical <br /> - ut- a°r bonnve <br /> Out-Of-Service Well Of-Se Ic enewaI Cross-Connection Repair <br /> New Pump Pump Replacement Pump Re p air Raise Well CasingEN <br /> WELL CONSTRUCTION /� <br /> Drilling Method Rotary Air Rotary /Kger Cable Tool Push Point Other C CEI VEp <br /> Proposed Well I H Excavation in diameter _ Open Bottom _ Gravel Pack/Gravel Size in diameter <br /> and c pLCa�!nIn diameter / Conductor Casing Depth Il PO + 20��Well Casing Diameterl �hGauge/ASTM Sched Steel L Plastic Stainless Steel Other IGroutSeal Depthlo-5eal Cement(94!b bag/5-10 gal water) _ Sand Cement sack mrx17 � <br /> Bentonite(20%solids) Other H ROHM UNTY <br /> Grout Placement Method Pumped Free Fall OthefjZqRM _ rdant/Accelerator(name) ENTAL <br /> PEDESTAL Installed By - Driller -Pump Contractor _ Other UEPaRTMNT <br /> Concrete Pedestal .Dimensions:Width tt Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible- Turbine Other HP Pump Set It Standing Water Level It <br /> I HEREBY CERTIFY THAT 1 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 COMP ANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR A NCE NOTICE REQUIRED FO INSPECTNS-PLEASE CALL(209) 3-*97 ^M <br /> SIGNED TITLE 0� V0 0 S DA iCJ <br /> 1A 11 <br /> ## <br /> DEPART ENT USE ONLY <br /> /j <br /> Application Accepted By Date �� / J✓�� Area Employee ID#� <br /> Grout Inspection By y ill/71J,t ci SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info Cash Remitted ervice Reauest# <br /> EMO C]-Oe !(i lraf5 � � 'CELL/FLIM PERMn <br /> 113 52.2�� U� �� d rl 1�' C��i �cctar 7 Z �w <br />