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i <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7123 <br /> ] A k CITY/ZIP� /744 t ' <br /> CROSS STREET U ,, AAPN/ 123l/ol Q/ a PARCEL SIZ.Z ft V LAND USE APPLICATION# <br /> OWNER NAME I �� r 1 t' t �--i r,jPHO`N,E r �ij(,,j( (...f f <br /> OWNER ADDRESS 2241 yj�-��(h��( 1�rt I^�,,�/I TCI(T�Y/S/TATEIZIP 1 I WhG�If�� I`�/`/ `�l/r�'r`J1 <br /> CONTRACTOR I V---! l w�'l.l J W(At-tr /"l/�l -+�V lti PHONE'Y.-V-1I RU ll O <br /> CONTRACTOR ADDRESS �3I l S (�L��1 (rYII�-t/1' CITY/STATE/LPA!ej� C1 D�4 <br /> SUBCONTRACTORICONSULTANT 1 �' / PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYI$TATE/ZIP <br /> LICENSE I)('C-57 -1 C-61 ❑D-09 U Other NUMBERq�glP',�.(_) EXPIRATIONDATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General MineraUColiform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Privale D Irrigation/Agricultural -Industrial n Water Quality Monitoring G Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well D Replacement Well Well Alteration/Modification D Other <br /> Monitoring Well(s) #of wells U Soil eoring(s) #of borings L Geotechnical III,of borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal n Cross-Connection Repair <br /> New Pump D Pump Replacement U Pump Repair 7 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary -1 Air Rotary 7 Auger D Cable Tool .,Push Point i; Other <br /> Proposed Well Depth ft Excavation in diameter -Open Bottom U Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched C Steel D Plastic !I Stainless Steel C Other <br /> Grout Seal Depth ft U Neal Cement(94 Ib bag/5-10 gal water) Cl Sand Cement sack mix/7 gal water <br /> n Bentonite(20%solids) 3 Other <br /> Grout Placement Method a Pumped U Free Fall 'S Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By i'Driller D Pump Contractor Other <br /> Concrete Pedestal❑Dimensions:Width ft Length it Thick in D Christy Box U Stove Pipe <br /> PUMP SubmersibleU Turbine n Other HP Pump Set jLL� ft Standing Water Level ft <br /> I HEREBY CER FY 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. 1 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 /> UM 48 HOU VANCE NO EQUIRED FORNSPE TIONS-VLEASE CALL(209) 5 <br /> SIGNED TITLE DATE <br /> 11711 11111 11111 <br /> RF rMFN <br /> AMY <br /> , <br /> 1 <br /> c �THO N/yFN��N�, <br /> EpgRr4f6Nr <br /> pEPARTMENT US ONLY A <br /> Application Accepted By [/� Date S 70ZO Area ���1 Employee ID# S j <br /> Grout Inspection By ^ , Date SPECIAL Well Permit <br /> Pump Inspection By � [,�6y (_j I,�.t F6� %, Date (�O lY WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth h <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permly Invoice# Well ID# <br /> Codes V/ Info <br /> B .Cash Remitted Service R ast# <br /> 0L:0 JK <br /> EHD43-06 6/112010 D X3503 3 Lf WELL/PUMP PERMIT <br />