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J UJa�-dls��z"l nPaLp%Y9 PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEP TMENT _ <br /> AR 1868 EAST HAZELTON AVENUE STOCKTON CA 96205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS CrrYZP I3?�0 <br /> -kAD <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# o <br /> re <br /> m <br /> OWNER NAME PHONE n Yri <br /> OWNER ADDRESS / V CnY/STATEILP I I r <br /> CONTRACTOR ' I PHONE <br /> CONTRACTOR ADDRESS CRY/STATEZPA_1�G <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE7ZIP <br /> LICENSE C-57 0 C-61 0 D-09 D Other NUMBER _ILExPIRATIDN DATE <br /> DOMESTIC WELL SAMPUNG:.I(S General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)3 Arsenic(4393) <br /> INTENDED USE omesfic/Pnvate 0 Irrigatioll/Agdrultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> fl Public Water System <br /> If dMerem/torn Owner: Water Syslem Nemo Contact Name or Phq Number <br /> TYPE Of WORK New Well d Replacement Well 0 Well Alteration/Modification 0 Other <br /> C Monitoring Well(s) #of wells 0 Sal Boring(s) s of bort ye 0 Geotechnical s.fborings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 0 New Pump D Pump Replacement 0 Pump Repair 0 Raise Well Casi <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Rota D Alr Rotary ❑Auger 0 Cable Tool 0 Push Point C Other <br /> Proposed Well eplhft Excavation�-in diameter 0 Open Bottom p Gravel PacklGravel Si.-.* in diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth J� ft <br /> Well Casing Diameter. n Thickness/Gauge/ASTM Sched J!VO 0 SteelPlastic D Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 It,bagrSlO gel wafer) Sand Cement sack mix(7 gal water <br /> )�entonite 20%Solids) D Other <br /> Grout Placement Method I Limped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller D Pump Contractor C Other <br /> 0 Concrete Pedestal DDimerrolons:Width_ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible[]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 /> MINIMPJA NOTICE REQUIRED F INS ECTI NS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE VDATE <br /> 4_, <br /> F ENT <br /> l SFO <br /> P ?020 <br /> Q01 <br /> oN� pV N rY <br /> Fp Tq� <br /> a TMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Grout Inspection By �� 'p�y.p <br /> Date 7 Area Employee ID# <br /> t!�,..��,�t.� .y.' r, y Date (:u iL�Z.��- ❑ 'SPECIALWellPermit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Sal Boring Inspection By Date <br /> COMMENTS Constructed Well Depth ft <br /> PE SC Received Check* Amount Permit/Codes Info B Cash Remitted Dab Service R nest K Invoice K Well IDK <br /> 4,, <br /> EHD 4aoe e Dura ! _ <br /> �/�� WELL/PUMP PERMIT <br />