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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAIELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMITITj CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I CITY21P 3� ,� <br /> _ D <br /> CROSS STREET APN 100 PARCEL SIZE LAND USE^/APPLICATTII�OIINN 0 8 <br /> OWNER N'E _ PHONE _0q <br /> OWNER ADDRE- CITYISTATE/ZJP Gd, ra 115337 <br /> /ff <br /> CONTRACTOR PHONE L�+- <br /> CONTRACTOR ADDRESS CRYISTATE.P_M Dab 7V. GLI 6JF7E�� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE )(C-57 D C-61 C 609 ❑Other NUMBER ExPIRAT)oN DATELA <br /> O <br /> DOMESTIC WELL SAMPLING: General MineraVCDliforTn Bacteria(4391)A.Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE f sticirPrivale J Imgation/Agncultural 2 Industrial -2 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If dfferent f—0— Water Syslem Name Co U.d Name or Phwe Number <br /> TYPE OF WORK XNew Well n Replacement Well Ll Well Mleratlon/Modification ;Other <br /> 0 Monitoring Well(s) 0 of wells U Soil Boring(s) sd0odrg. C Geotechnical edbon"'ge <br /> D Out-0f-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> _ I I New Pump U Pump Replacement C Pump Repair LI Raise Well Casing <br /> WEI,L CONSTRUCTION <br /> Drilling Method Mud Ro [;Air Rotary L Auger C Cable Tool 0 Push Point 0 Other <br /> (Proposed Well Depth R Excavator 1�— in diameter G Open Bottom AGravel Pack/Gravel Size In diameter <br /> it Conduct Cis in diameter / Conductor!Casing Depth It yME <br /> Well Casing Diameter in Th,.ness/Gau9e/ASTM Sched�V L Steel Plastic -,Stainless Steel �OtMr ece/v D <br /> Grout Seal Depth It C Neat Cement(94 Ib bagr5-10 gal water) :]Sand Cement sack mixt'?gal water ED <br /> Bentonite(20%solids) C Other <br /> Grout Placement <br /> 'Bentonite <br /> umped L Free Fall D Other L Retardant/Accelerator(name) 2 3 2020 <br /> PEDESTAL Installed By C Driller 0 Pump Contractor C Other <br /> ,]Concrete Pedestal DDlmensions:Width It Langth R Thick in 0 Christy Box ❑StoveRAV, q Qu)N <br /> PUMP C Subm nubie-I Turbine 0 Other HP Pump Set It Standing Water Level RONMENLq NTy <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN DEPgRT1yIENT <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE W TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU O C CE REQUIRED FOR INSPECT NS-PL SE CALL(209 9 3-7697 <br /> SIGNED TRLE f_r DATE ✓�/ <br /> `v N <br /> I <br /> I I <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By L Dale 6 03 Area - Employee IDN S!� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date .r-i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received i�j <br /> Amount Date Permit/ Invoice A Well IN <br /> Codes Info B Remitted Service Request A <br /> �o <br /> 4ry <br /> 77Sw- j70 <br /> /� �/( 1/� Y/Fl l,P 11MP PERMIT <br /> EHD43-06 010111E 1 v/v J-' <br />