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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1568 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1`YEAR FROM DATE ISSUED <br /> JOB ADDRESS -�Ie) 1 v I L,I'C'M Y r1 A- S C"a", C.I '`^('rl T J N <br /> CROSS STREET 'I�'1 J r^�C.I APN PARCEL <br /> SIZE !(r /LAND USE APPLICATION>K o <br /> 1 F <br /> OWNER NAME .JGC' 1 Sc PHONE m <br /> OWNER ADDRESS J CIM e- CfTY/STATEZP "'� �7 <br /> CONTRACTOR C 1 n C' PHONE JY:`l - "f 7 / <br /> CONTRACTOR ADDRESS` C- C, CITY/STATEZP /Ci 1CA .� <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEZP <br /> LICENSE C-57 XC-61 _D-09 Other NUMBER -2fi 3, 3 EXPIRATION DATE <br /> 7'3� 2C <br /> BILLING PARTY: OWNER ONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DoMEsnc WELL SAMPLING:; General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE C Domestic/Private 7 Inigation/Agricultural Industrial C Water Quality Monitoring C Soil Sampling/Characterization <br /> i:i Public Water System <br /> If different horn Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ".Replacement Well D Well Alteration/Modification i Other <br /> Monitoring Well(s) #Of Wells C Soil Boring(s) "boring'bonne' D Geotechnical #of bonngs <br /> Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair <br /> ecu Pump - PumpXPump Replacement C Pump Repair Raise Well Casing <br /> WELL CONSTRUC11ON <br /> Drilling Method Mud Rotary Air Rotary -- Auger D Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter -Open Bottom =:Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad - Steel Plastic -Stainless Steel Other <br /> Grout Seal Depth ft D Neat Cement(94 lb bag/5-10 gal wafer) - Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped Free Fall �_i Other .-.Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller D Pump Contractor Other <br /> Concrete Pedestal;]Dimensions:Width ft Length it Thick in D Christy Box f':Stove Pipe <br /> PUMP Submersible.-;Turbine C Other HP Pump Set r It 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 /> MINIMU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76q-- <br /> SIGNED , TITLE 1 C Ee �t�C' C'1� DATE JZAT)c <br /> _ F YMFN <br /> cF�AFD <br /> AY 18 ?D <br /> ?0 <br /> ��V'Ozvm"QUIN <br /> EPLARTME USE pQMENT y <br /> ,,p ONLY + 7� G T <br /> Application Accepted By r' G— Date�1�$ 7'2 � Area y/�C� Employee ID# L)rL <br /> Grout Inspection By Date ._� SPECIAL Well Permit <br /> Pump Inspection By diY.;5 -1,';-- Il Date � f I� - WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Into Cm. Remitted Date ervice Re neat# Invoice# Well ID# <br /> 3PVS-12 - V7 :Z L <br /> E4D 43-09 8/1720'v � _4 ��fJ 7/ /3� /6(/S �o / WELL rPUMP PERMIT <br />