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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1969 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> �• rn <br /> Joe ADDRESS t l J i C.TY/71v <br /> 1 1F�-141�-�Q 1�2 <br /> CROSS STREET WAVN /A�P`N^ PARCEL SIZE LAND USE APPLICATION 0 T <br /> OWNER NAME �►j]_►►1 �\ \l .✓< 1 _ PHONE ) a <br /> In) t . <br /> OWNER ADORESL _ .�i_ n/''� CITY/STATE2l: 6 ( "/t -fnC^I�`yo� <br /> CONTRACTOR �� \/r..��/ �\\ \\ J �PHO �/W� \ t{X�V L(��I v�A�1�1"1, <br /> CONTRACTOR ADDRESS VD-*AL,,)ry(0 p�lV.�/J CITYISTATE/ZIP[nNh a�llnl L.CT(�'�/ 1 Q <br /> SUBCONTRACTORICONSULTANT_L](1_\]- PHONE <br /> SUBCONTRACT)ORICONSULTANTADDRESS we t- �`{{CITYIS(T'AAT�E(/JP �/� <br /> LICENSE /C-57 C•61 0-09 Olhe/ NUMBER `� •`+Ib EXPIRATION DATE 02-1 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomestictPnvale Irngation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> II rnaerent I—Owner Writer System Nnme C-1-1 Namu or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well APeration/Modification Other <br /> Monitoring We0(s) R of wells Soil Bonng(s) sot Donnas Geolechnlcal x of boring, NO!tj' <br /> /Out-Of-Service Wel) Out-Of-Service Well Renewal Cross-Connection Re w y� AA <br /> New Pum Pum Replacement Pum Repair Raise Well Casing �{K Q.x`fl iv,11 to <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger 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 fl <br /> Well Casing Diameter_in Thickness/GaugefASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth h Neat Cement(94!o Dagi5-10 gal water) Sand Cement Sack m,x11 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions-Wdth it Length It Thick in Christy Box Stove Pipe <br /> PVMP Submersible Turbine Other HP Pump Set:IZ ft Standing Water Level h <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY DINANCES, STATE LAWS, RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT <br /> AND <br /> Tl 411TH TH CALIFORNIA CO RACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS Co O <br /> MINI 4 DV CE IRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> • qC MENTI <br /> t <br /> -4 A 11, r EI V ED <br /> G 2 4 ?020 <br /> N� 4 T4 <br /> pLTY <br /> �RTr✓�ENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Data ✓6A Area / it`r Employee IDB 1 f <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By E ii e+�l-L,y Z-wa•. 4L Date "I j.".'1.J WAIVER Received <br /> Soil Boring Ins�pe�ction By Date Constructed Wel)Depth H <br /> COMMENTS �= 1 reft"I .MiG, T :i Sl'/L''<F PE SC Received Chock#/ Amount Date Permit/ Invoice 0 Well IDTt <br /> Codes Into %Cash Remitted Service Request e <br /> !°<E+'i Tx 2 I <br /> 11,21-85-3-67/ <br />