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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46"420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS All <br /> Cm/Lv to <br /> CROSS STREET ZO. APN 1-70 PARCEL SIZE LAND USES A,[P�rPLLICATION# C <br /> OWNER NAME PHONE Y�"•• qO'q•G' <br /> OWNER ADDRESS r O CITY/STATEM <br /> CONTRACTOR 1 PHONE i�0 f�fiGI 1 ''7 <br /> CONTRACTOR ADDRESS 11A wc Mi. CrrY/STATEMPDOX (A <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CFTY/STATErz'P <br /> LICENSE IX, 0 C-61 0 D-09 n Other NUMBER SID t022 EXPIRATION DATE01 <br /> • 20Z� <br /> DOMESTIC WELL SAMPLING:A General MineraUColiforrn Bacteria(4391),)]Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE mestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Charactenzation <br /> C Public Water System <br /> If different from Owner: Water System Name Cmtxt Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well U Well Afteration/Modification U Other <br /> 0 Monitoring Wall($) #of wells 0 Soil Boring(s) sof Wrings L Geotechnical xof borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION// <br /> Drilling Method ',AMud Rotary 0 Air Rotary C Auger 0 Cable Tool C Push Point U Other <br /> Proposed Well Depth:?,�N it Excavation 1-11 —in diameter n Open Bottom Gravel Pack/GraVel SIZ.�4 in laMeler <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. ���h(lc(krrjess/Gauge/ASTM Schad 11 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seat Depth �n( 0 Neat Cement(94!b beg/5-10 gel wafer) 0 Sand Cement sack mix/7 gal water <br /> D4enlonde(20%solids) 0 Other <br /> Grout Placement Method Wl(umped 0 Free Fall U Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> n Concrete Pedestal ODlmensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Plpe <br /> PUMP 0 Submersible0 Turbine 0 Other HP Pump Set ft Standing Water Level ft <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 /> MINI ANCE NOTICE REQUIRED FOR I SPIT IONS-PLEASE CALL(209)953-7697�t J� <br /> SIGNED M <br /> TITLE C 1 DATE <br /> RFq yMF <br /> q cF��FO <br /> q �0 <br /> �Rp ViN <br /> �AqR��NTY <br /> ' M <br /> Fell "T"I <br /> ic� AW <br /> NT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By IT17N Date Area "t + Employee ID# <br /> Grout Inspection B)( MMN Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 31-7 ft <br /> COMMENTS <br /> PE SC Received Checks/ Amount Data PermIV Invoice# Well IDS <br /> Codes Info 8 Cash Remitted Service Req uest# <br /> 7L L <br /> I�� 4 it II <br /> EHD X3-08 8101/18 / %����D� WELL/PUMP PERMIT <br />