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� 1 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STocKTON CA 96208-(209)468J420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> c;k UrrymP, � 9��30 > <br /> JOB ADDRESS ° r v <br /> CROSS STREET K nnP�('i�'K <br /> APN f'CX� PARCEL SME/LAND USE APPLICATION# pq <br /> �YriQl 1 L—fw't PHONE <br /> OWNER NAME <br /> c-1 1 1 L v P C.�CK Rd• CITYISTATE/ZIP� `JG <br /> OWNER ADDRESS t'? ` Q <br /> CONTRACTOR �►Y-0o 151x]? vt n�P r'V t�_P PHONE I S� <br /> O <br /> 3 ��•t►Alt i1�(` �I,y-� CITYISTATEMP <br /> CONTRACTOR ADDRESS ",f1� <br /> Ina Lf q2ho 3a= <br /> PHONE <br /> SUBCONTRACTOR <br /> CtTYISTATE/ZIP <br /> SUBCONTRACTOR ADDRE35 <br /> LICENSE 57 ::C-81 =D-09 --Other <br /> NUMBER Ds EX%RATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliforrn Bacteria(4391)--Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED UaE ❑Domesdrivnvate C Inigadon/Agdcullural _Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization <br /> C Public Water System omsat <br /> CName w ne PhoN..V l <br /> It dleerent hom Owner Water SystName E: <br /> N <br /> TYPE OF WORK :1 New Well C Replacement Well C Well AlleradonlModification J Other J Geotechnical a of boongs l• V v <br /> ED <br /> �Monitoring Wells) #of wells ^Sail Boring(s) #or borings <br /> Out-Of-Service Well C Out-Ot-Service Well Renewal C Cross-Connection Repair 012020 <br /> 'New Pu G Pu Re lacement 7 Pump Repair �:Raise Well Casi <br /> WELL CONSTRUCTION C ��N J A QV I N <br /> Drilling Method Mud Rotary G Alr Rotary C Auger E Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter G Open Bottom C Grftvel Pack/Gravel Size pE�MENT,L TM <br /> [;Conductor Casing In diameter / Conductor Casing Depth ART G Plastic C Stainless Steel -Other MENTI <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel _Sand Cement sack mixll gel water <br /> Grout Seal Depth ft D Neat Cement(94 Ib bag/5-10 gal water <br /> Bentonite(20%solids) G Other ❑Retardant/Accelerator(name) <br /> Grout Placement Method _;Pumped C Free Fall -A Other <br /> PEDESTAL Installed By O Driller C Pump Contractor C Other ft Thick in c Chrfsty Box C Stove Pipe <br /> Concrete Pedestal'7Dimensions:Width ft Length <br /> PUMP SubmersibleEi Turbine ,-.Other <br /> HP Pump Set it Standing Water Level It <br /> I HEREBY CE FY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> I ALSO CERTIFY THAT My REQUIRED IS <br /> JOAQUINCURRENT AND COUNTY <br /> CTIVEINANCESWITH THESCAL CALIFORNIA CONTRACTORS STLAWS,AND RULES AND ATE LICENSE BOA D AND THAT AM IN COMPLIANCE LICENSE WITH ALL <br /> WORKERS COMPENSATION LA <br /> V�CE NCE REQUIRED F—OATNSPri`OPLEASE CALL(209)95 -�7�697 <br /> MINIMUM 24 HOUR TITLE DA <br /> SIGNED �� <br /> DEPARTMENT USE ONLY <br /> Dale v- D! J" Area q of Ci Employee ID# <br /> Application Accepted By G SPECIAL Well P@rrTlit <br /> Grout Inspection By Date_T <br /> Pump Inspection By �• <br /> r L Date LOLIa t' t- WAIVER R@C@IV@d <br /> Date <br /> Constructed Well Depth_it <br /> Soil Boring Inspection By <br /> COMMENTS <br /> Permit/ Invoice# Well ID# <br /> PE Sc Recelved Check#/ Amount Da Service Re Most# <br /> Codes Into Cash Remitted <br /> ISO <br /> WELL/PUMP PERMU <br /> EHD<Sge 5MIM6 <br />