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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.siqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> c' Z, N <br /> JOB ADDRESS / CITY/ZIP C�h• <br /> C /J� I D <br /> CROSS STREET :J,' L// ARCEL SIZE �1• L N6 USE APPLICATION# <br /> OWNER NAMEC`/7 ONE <br /> N <br /> t j1 <br /> � - <br /> OWNER ADDRESS ITV/STATE/ZIP�9 /--/ <br /> CONTRACTOR - PHONE i/, �/-� — 7� Q <br /> CONTRACTOR ADDRESS ��"� �!/ L—C- CITY/STATE/ZJP <br /> SUBCONTRACTOR/CONSULTANT /-tJ���S /,/ �/�� PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITU/STATE/ZIP <br /> LICENSE 057 `�C-61 D-09 Other NUMBER ''fm EXPIRATION DATE 15 <br /> BILLING PARTY: ..OWNERONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:LI General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Imgation/Agncultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> V d1'Ixlenl I—OvmerWater System Nama Contact N.—or Phone Nurtilxr <br /> TYPE OF WORK New Well (Replacement Well Well Alteration/Modification Other <br /> U Monitoring Well(s) #of wells Soil Bonng(s) °°`b°""us Geotechnical "O`bo-U. <br /> t;Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUtTION <br /> DrillingMethod ud Rota Air Rota Auger -,,Cable Tool Push Point Other <br /> Rotary 9 <br /> Proposed Wel Depth ft Excavation /d7— in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in thickness/Gauge/ASTM Sched�% Steel �Flastic Stainless Steel Other <br /> rout Seal Depth /ft Neat Cement(94/b bag15-10 gal Water) ' _Sand Cement sack mlx(7 gal water <br /> )Iptentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ump Contractor Other <br /> Concrete Pedestal D ensions:�Mdth It Length It Thick in Christy Box Stove Pipe <br /> PUMP ubmersible Turbine Other HP Pump Sel- fl Standing Water Level <br /> 1 HEREBY C RTIFY 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 CO N ION LA <br /> /'At OT10E REQUIRED FOR <br /> /i��'y9PECTIONS-PLEASE CALL(209)953--69- <br /> SIGNED �•'Y TITLE_ /�� � DATE <br /> s— YMENT <br /> i <br /> FIVE® <br /> - - 05 2o2o <br /> WIN <br /> NMENOTAL 7Y <br /> PAR7-MENT <br /> I <br /> if AS <br /> rs <br /> c <br /> E P A R T M E N T US ONLY 'l <br /> S <br /> Application Accepted By O Date 6 J� Area Employee ID# `� <br /> Grout Inspection By r:v•vL:��+ �.� .. 1R.ti� Date 11� �° SPECIAL Well Permit <br /> Pump Inspection By C�4tai, S Lv (rte-n�y���w.>L Date_ I rl':'L•4 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well eptli <br /> � 5 ti <br /> tt, <br /> COMMENTS bJ(?)I 7 y,," c'+5 SIL F Or�71pPc T�/ INF JJ �Pe} r�M 1f01'1 �Jr,pf`1y y`nt <br /> PE SC Received Check#/ Amount Dale Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted S rvice Reguest# <br /> y3K� 0�0Alt ; --- L <br /> n p U L � <br /> EHD 43-W 6111 Or 19 WELL/PUMP PERMIT <br />