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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS W.T G� CITY/LP <br /> CROSS STREET �+• -:/c APN� 1 `�`-� -1 PARCEL SIZE'1)1 LAND USE APPIJ ATION# D <br /> 1 <br /> OWNER NAME Y> '1 '-k LCL.r( PHON V-` J�V lJ 'm <br /> OWNER ADDRESS CITYISTATEMPI�"� Cl /�( L♦ <br /> CONTRACTOR iMAI 1ffiag PHONE�}/',L/t I`^[(J • C"V�`y� <br /> CONTRACTOR ADDRESS ` -b G(' I :LL(o1 , CITY/STATEZP �V(( ,✓`L CtF36c7 <br /> SUBCONTRACTOR/CONSULTANT ` `� W PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE XC-57 G C-61 D-09 l Other NUMBER 0`44 W EXPIRATION DATE ` U <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private X rigation/Agricultural �.Industrial a Water Quality Monitoring Soil Sampling/Characterization <br /> G Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew WeII 7 Replacement Well Well Alteration/Modification Z Other <br /> Monitoring Well(s) If of wells Soil Borings) r of borings Geotechnical If of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal I Cross-Connection Repair <br /> J New Pump n Pump Replacement ❑Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method/Mud R afrry``�Air Rotary 0 Auger able Tool D Push Point G Other <br /> Proposed Well Depth VV ft Excavation in diameter C Open Bottom Gravel Pack/Gravel Size in diameter <br /> C Condetuc or Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamer In Thiicck�ness/Gauge/ASTM Sche Z\ ;;Steel APlastic _:Stainless Steel Other <br /> Q <br /> Grout Seal Depth U Neat Cement(94 Ib bag15-10 gal wafer) L Sand Cement sack mix/7 gal water <br /> ,Xventonite(20%solids) 0 Other <br /> Grout Placement Method Pumped Free Fall 0 Other :;Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller X3ump Contractor 0 Other <br /> ❑Concrete Pedestal ODlmensions:Width_ft Length ft Thick in L.Christy Box D.Stove Pipe <br /> PUMP ❑Submersibles!Turbine C Other HP Pump Set ft 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 /> MINIMUI U ADVANCE/NOTICE REQUIRED FOR INSP.E TIIO,NNS-PLEASE CALL(209)9 3-7 97 <br /> SIGNED / \� TITLE �rI ��" r DATE .2-0 <br /> RE YMENT <br /> CFjV�D <br /> oG 8 ?020 <br /> A ���MFN q�NTy <br /> RTMEN7' <br /> DEPARTMENT YSE ONLY y <br /> Application Accepted By � -" ` Date /7 ck b Area Employee ID# >l� <br /> Grout Inspection By t1. . Date i���-� SPECIAL WeII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By ateC�structed Well Depth J ft <br /> COM ENTS (� J ( ' l <br /> C uk S . <br /> PE Sc Received Check#/ Amount Date <br /> LOC 1 Pertnitl Invoice# Well ID# <br /> Codes Info Cas Remitted Service R nest# <br /> d 0 l� <br /> EHD 1. 11(1019 <br /> pa� � WELL/PUbIP PERMIT <br />