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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENmoNNENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTON AVENUE•STOCKTON CA 95205-6212(209)488-3420 <br /> NON-REFUNDABLE PERMIT www.sjqov.orq1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> n+,��► Z N <br /> �JOH AODR£ss 1` J% Crrv/Lv L�'� 1 <br /> a <br /> i <br /> CROSS STREET ` _ ARCEL St2E + !16 Use APPLICATION It <br /> OWNER NAME <br /> OWNER AODR£be TY/STATEIZIP �f <br /> CONTRACTOR l'� L-40 <br /> �] 1 �_ PMONE <br /> CONTRACTOR ADDRESS �` "'/�'r/�y��t � CITY67ATEZP <br /> SUBCONTRACTORICONSULTANT C PHONE <br /> SUSCONTRACTORICONSULTANT ADDRESS CtTYiSTATEZP OC <br /> LICENSE )&57 XC-61 D-09 Other NUMBER.�iCii_ EXPIRATION DATE_ � r <br /> BILLING PARTY' OWNER ACTOR SURCONTRACTOWCONSULTANT <br /> DOMESTIC WELL SAMPLING:, General Mineral)Coliform Bacteria(4391) ,Dioromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ;VC--c/Private InigationrA.g6cuhurel _ Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> 0 Public Water System <br /> If dowsr t from 0a Whet Syetem Nano Camad Name a Phwio N,m+Ger <br /> TYPE OF WORK 0 NOW Well Replacement Well "0 Well AlterationiModificaton i<DOW <br /> MonitoringWefl(s) sof welt 0 Sol Soring(s) sorbwartp Geotechnical twb°`v,g, <br /> Out-Or-Service Weil C..Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump Pump Replacement C.Pump Repair J Raise Well C"na <br /> We"CONSTROI!1ION <br /> Drilling Method Rotary Air Rotary Auger Cable Tool ..Push Point c' Other <br /> Proposed Wel Oepm to rt Excavation 17— in diameter Open Bottom ravel PaddGravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth It <br /> Well Cuing Diameter in ThicxnesslGaugerASTM Sched Steel ;�FlaStic Stainless Steel .Omer <br /> rout Seal Depth I ft Neat Cement(9d Ib bag/5-TO gal wafer) J-Sand Cement sack mrx/7 gal water <br /> ,X*antontle(20%solids) Omer <br /> Grout Placement Method Pumped ..Free Fall Other _:Retardant l Accelerator(name) <br /> EEDESTAL Installed By .:OrMef mp Contractor Other <br /> Concrete Pedestal.: ens(ons:Width h LengthR Thick in - Christy Box Stove Pipe <br /> P IMP ubmersible- Turbine - Other HP 3 Pump Set ft S., Water Level__ <br /> I HEREBY C RTIFY 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 CO ON LA <br /> MINI O A �OTICE REQUIRED FOR I PECTIONS-PLEASE CALL(209)953-1697 <br /> SIGNEO �TITLE✓�. DATE <br /> II Jk 1,# YME�vr <br /> ElVEp <br /> 711 <br /> - - 0 5 Z020 <br /> UIN COUNTY <br /> FZONMENTAL <br /> i PAR <br /> TMENT <br /> I I ' <br /> i <br /> I. I <br /> EPARTMENT US ONLY <br /> Application Accepted By "� "� Date Jifr/ O'�O Area d Employee IDO O <br /> LA <br /> Grout inspedion 8y �r y ' Date SPECIAL Wel)PerMit <br /> Pum inspeu;a,By '� t+ "' Date ���3�'w�'l.-U t.l WAIVER Received <br /> Soil Boring bt Trion By Date —�. ConstnMetad Wiap��pth y hhJ <br /> COMMENTS veli 2T� Yo 7y+ PC15 sl e 0.r D10 r TV )lila �� rft+ ( `mJto mr) O 3ipl'J ��rQ <br /> PE SC Received CheckMl Amount Date Permit/ Invoice N Well IDN <br /> Codas Info Cash Remitted a Request 9 <br /> y3,KC; o�0itISS _ <br /> NJ V Ill v1� <br /> EHJ�ltltl alt lrlate WELL RUMP PERNR <br />