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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDA13LLE�rPErRMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> SS <br /> JOB ADDRE /'�-r'j Lf' P aLT r c)'L �y>-�7 / CITY21P AL n 7-1 M2 `r�Z ZL"� LnLn <br /> D <br /> CROSS STREET P l.1 5 i I r-/ / , APN 1b5�-Z6o-'OLS/ PARCEL SIZE LAND USE APPLICATION# O <br /> m <br /> OWNER NAME - - - H <br /> aq - PHONE Zt <br /> OWNER ADDRESS -701 1 �, Zy-=r j�JZ, CITY/STATE/ZIP-Acejz�J C7 Z�Zi �7 <br /> CONTRACTOR �IA-L PHONE <br /> e-7 <br /> CONTRACTOR ADDRESS C l—1 0`�S'�'~( 1,-Y CITY/STATE/ZIP LJ)i 6-4 <br /> SUBCONTRACTOR /�/its PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ,:-t-57 I I C-61 i,D-09 I I Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:I i General Mineral/Coliform Bacteria(4391) !Dibromochloropropane(4392) z Arsenic(4393) <br /> INTENDED USE Domestic/Private I Irrigation/Agricultural 1'Industrial I Water Quality Monitoring xsoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORN 1 New Well I I Replacement Well 11 Well AlterationlModificalion 11 Other <br /> IiMonitoringWell(s) #of wells - SoilBoring(s) 'I'- of borings iIGeotechnical of borings <br /> I Out-Of-Service Well I I Out-Of-Service Well Renewal I_I Cross-Connection Repair <br /> i New Pump i i Pump Replacement 1 I Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 1 i Mud Rotary I Air Rotary Auger I 1 Cable Tool Push Point i Other <br /> Proposed Well Depth 1_ft Excavation (� in diameter 1 Open Bottom i Gravel Pack/Gravel Size in diameter <br /> 1 I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched I I Steel I I Plastic 11 Stainless Steel I I Other <br /> Grout Seal Depth r it eat Cement(94 lb bag/5-f0 gal wafer) I Sand Cement sack mixl7 gal water <br /> I I Bentonite(20%solids) I I Other <br /> Grout Placement Method I Pumped ZFree Fall f 1 Other l i Retardant/Accelerator(name) <br /> PEDESTAL Installed By I 1 Driller I 1 Pump Contractor Other. <br /> 1 I Concrete Pedestal 1Dimensions:Width it Lengthft Thick in Christy Box IStove Pipe <br /> PUMP I Submersible i I Turbine I Other HP Pump Set ft Standing Water Level ft <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 COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE R QUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -7697 <br /> SIGNED '� TLE 1 t1 G/ DATE <br /> � r 9 <br /> 9A a4 U4.01 NTY <br /> l E I O E T L <br /> H I H A ENT <br /> EPARTM /T USE Y <br /> Application Accepted By Date <br /> a � Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit: <br /> Pump Inspection By �h,II Date WAIVER Receive( <br /> Soil Boring Inspection By A Date Constructed Well Depth tt <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> EHD 43.06 8/01116 WELL/PUMP PERMIT <br />