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ro 17yy <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Jos ADDRESS / DL� A u5+/ n CITYIZIP l m <br /> Vo <br /> I D <br /> CROSS STREET f jh G&' APN >]f` J PARCEL SIZE I r�l�pNQ USE APPLICATION <br /> OWNER NAME (� MPHONE 21e'7 <br /> 11102-2- <br /> ,r IJ���1L�•� <br /> OWNER ADDRESS AuS+tl"I I��- _ CITYISTATE/LP /��QC'�7L— <br /> CONTRACTOR OL1,r0\Al `o 7 <br /> PHONE C.V 1• I/I'5` (o.27(0 <br /> i H <br /> CONTRACTOR ADDRESS I V V 3l~f.Ic. L7h P_ Iz CITY/STATE(ZIP M � 61 I CA ,63,3((j <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE I I C-57 C-61 I::-D-09 I I Othef NUMBER 11!1 7�1 fo EXPIRATION DATE 8 3 I 1 ZQ 2, <br /> DOMESTIC WELL SAMPLING:':i General Mineral/CDllfofm Bacteria(4391) I Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE omeslicJPrivate 0.1nigation/Agricultural Industrial Water Quality Monitoring I Soil Sampling/Charaolenzation <br /> ❑Public Water System <br /> II dill arenl Iram Owner: Wafer S"Itinl Name Contact Name ar Phone Numbar <br /> TYPE OF WORK New Well I I Replacement Well I Well Alleralion/Modification i;Olher <br /> I 1 Monitoring Well(s) it of wells I:Soil Bonng(s) If.(b.ni­Ig' I Geotechnical tl of harintle <br /> n e,1,01-Service Well t 1 Out-Of-Service Well Renewal i:Cross-Connection Repair <br /> w Pum i I Pump Replacement i t Pump Repair i i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary ;I Alr Rotary 1 I Auger I i Cable Tool I i Push Point I 1 Other <br /> Proposed Well Depth ft Excavation in diameter 1:Open Bottom I I Gravel PackiGravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad I Steel I Plastic I Stainless Steel Other <br /> Grout Seal Depth It rl Neat Cement(94 Ib bag/5-70 gal water) !Sand Cement sack mix17 gal water <br /> f1 Bentonite(20%solids) I Other <br /> Grout Placement Method-L Pumped ;.I Free Fan 1 Other Retardant/Accelerator(name) <br /> PEDESTAL Inpiralled By 'J Driller ump Cenlractgr Other <br /> './Concrete Pedestal I!Dimensions:Width 4 N Length ft Thick in Christy Box i Stove Pipe <br /> au jtgubmerSiblel i Turbine I I Other HP Pump Sei I "', it Standing Water Levelft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLJCATION 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 CO�MPS"ATT S <br /> . <br /> MINI Ott HC3UCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE F'L�� DATE <br /> do <br /> LL <br /> FZ�G� <br /> MPS 2 <br /> a <br /> SPEP�N <br /> N� I <br /> I <br /> DEPARTMENT USE ONLY <br /> s SI< <br /> Application Accepted By e----7Z 1-4- Dale � 2/ Z`1 Z':' Area / Employee ID <br /> Grout Inspection By Dale .! SPECIAL Well Permit <br /> Pump Inspection By 1-J iin TS— (L+j L.tU•L- Date \v���-ri-1-1.' WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit! Invoice# Well ID# <br /> Codes I Info 8 ash Remitted ervice Re uest# <br /> EHD 4-0e raNsed Ql4t16 WELL(PUMP PERMIT <br />