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'' 1oi838 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDARI E PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED In <br /> JOB ADDRESS � I I )f CITYfZIP l Soo; m <br /> _ _ > n <br /> CROSS STREET <br /> .lr1C -7 `>-D�T PARCEL SRE�'I"')LAND USE APPLICATION# a <br /> — 0� itsI-SbOD <br /> PHONE <br /> OWNER NAME <br /> OWNER ADDRESS e! J / S /• 1�/ I C{� �C Clll'lSTATE/ZIP <br /> CONTRACTOR Q �D 1 `JY7 I PHONE Z09. /1'5� (0�7ln <br /> RESS <br /> CONTRACTOR ADDI I SG GIC. L7�P. K!� CITY/STATEIZIP M(Al'�}e �` I CA 9 3,3(Q <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE I I C-57 C-61 1:D-09 I I Other NUMBER_LD y. (o EXPIRATION DATES 1-3) ZO 2 <br /> DOMESTIC WELL SAMPLI G::I General MinerallCoUarm Bacteria(4391): Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE _ omestic/Private C) IRlgatlonlAgricullural I Industrial :Water Quality Monitoring I Soil SamplinglCharadenzalion <br /> G Public Water System <br /> II dill—A from Owner: Wale,SyMen,Nam, C-1-1 Neem .Pin-Nwnb°r <br /> TYPE OF WORK ew Well l Replacement Well i:Well AlteralioniModlfication I I Other <br /> Monitoring Well(s) #of wells i:Soil Boring(S) "0l b"""" I Geolechn,cal u of x11114: <br /> 1 Oul-Of-Service Well 1 Out-Of-Service Well Renewal 1 Cross-Connection Repair <br /> {fFlew Pum ;PLmp Replacement Pump Repair I Raise Well Casing <br /> WELL CONST RUCTION <br /> Drilling Method 1.:,Mud Rotary 1 Air Rotary 11 Auger I I Cable Tool Push Point I,. Other <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom 1 i Gravel PacklGravel Size in diameter <br /> _l Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Scheid I,Steel 1 Plastic :Stainless Steel I Other <br /> Grout Seal Depth R I I Neat Cement(94 Ib bag/5-10 gal water) 1 Sand Cement sack mixt gal water <br /> I_!Bentonite(20%Solids) i I Other <br /> Grout Placement Method ❑Pumped I I Free Fail I Other :1 Retardant I Accelerator(name) <br /> PEDESTAL Ins ed By it Driller 1:Pump Contracto ! Other <br /> oncrete Pedestal l!Dimensions:Width ft Length It Thick " in Christy Box Stove Pipe <br /> PUMP ubrnersiblell Turbine I I Other HP= PumpSel II Standing Water Level <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 COMP SAT WS. <br /> MINI ) /�ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9 3-7F97 <br /> SIGNED +� J, Y TITLE ' "���^ DATE S ZZ <br /> _ EYN►ENT <br /> CEWE p <br /> ~ , 212020 <br /> E <br /> RE �ANTY <br /> DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By -7-2—'" E Date �) 7 4 Area ' Employee IDB <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By k-11` 14.S L-. &r,_ `l. Dale 12 "I 71y,':v I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received CheckPI Amount Date Permit/ Invoice# Well IDP <br /> Codes Info Cash Remitted Service Reauncl a <br /> 1 <br /> EHD 43-05 reVleee 114118 "ELL 1PUMP PERMIT <br /> -77 <br />