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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAom DEPARTMENT 1868 EAST HAMILTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> ' NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1//t.. jo w <br /> JOB ADDRESS � / � � �7 Cr1YMP / <br /> CROSS STREET �- n� <br /> � / i PARCEL SME LAND USE APPLICATION# a <br /> OWNER NAME 31y-- PHONE ��7 LIS <br /> '/ �C 7/ <br /> OWNER ADDRESS ? l �\ 'Y CITY/sTATEZP <br /> CONTRACTOR /�il/y�� L.ti 1"V��yl[�'�' `►Y) 1[� 2 '-APHONE�7L fI J�G' �-/I'�-121111 7 Y <br /> CONTRACTOR ADDRESS S /� fry^f /�J C3 CRYISTATEIZIP[./A I`��-le `I.6! -l <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIT'ISTATEIIZIP^ <br /> LICENSE -C-57 -C-61 _D-09 Other ' NUMBER[[��i�L7�C-" EXPIRATION DATE,�i- <br /> DOMESTIC WELL SAMPLING:-.General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)=Arsenic(4393) <br /> INTENDED UsE ADomestic/Private -Irrigation/Agricultural =Industrial =Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If di8emnt fmm Owner. Wate,System Name Conrad Nam or Phone Number ®p <br /> TYPE OF WORK D New Well ::Replacement Well (.. Well Aneration/Moditiration G Other <br /> Y of borings <br /> Monitoring Wells) II of wells -. Soil Boring(s) -Geotechnipl 0 of borings 4v ■ _ <br /> L'Out-Of-Service Well Out-Of-Service Well Renewal '_Cross-Connection Repair �® <br /> New Pump Pump Replacement Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -..Mud Rotary _Air Rotary -Auger Cable Tool =Push Point - Other SARI 019 <br /> Proposed Well Depth ft Excavation In diameter -Open Bottom E Gravel Pack/Gravel Size in dianem ON <br /> ACO <br /> r) <br /> _Conductor Casing in diameter / Conductor Casing Depth If H4L O rUNTI <br /> Well Casing Diameter in ThicknesslGauge/ASI M Sched -Steel --Plastic -:Stainless Steel C Other FPgZrk ,7 <br /> Grout Seal Depth ft _Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixR gal water ANT <br /> -Bentonite(20%solids) --Other <br /> Grout Placement Method ..Pumped '_Free Fall Other _Retardant I Accelerator(name) <br /> PEDESTAL Installed By --Driller ,Pump Contractor - Other <br /> Concrete Pedestal-Dimensions:Width If Length ft Thick in Christy Bos -Stove Pipe <br /> Pum Submersible:Turbine - Ottley HP Pwnp Set R Standing Water Level rl <br /> I HEREBY CERTIFY THAT 1 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 /> UM 48 HO R ADV E NOTICE REQUIRED FOS INSPE/C�TiOty�-PLEASE CALL(209)953-7697 <br /> SIGNED -t— TITLE`,("'�lil,-I,44 DATE <br /> V" <br /> P A T M E N T U E O L Y <br /> Application Accepted 8 e Z Area Employee ID# <br /> Grout Inspection By Date 3 SPECIAL Well Permit <br /> Pump Inspection By Fr't rtt., I:, l yr L Date �� 14bDi-' ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS - <br /> PE SC Received Check#! Amount PermiU <br /> Codes Info B Cash muted Date erviceRe uest# Invoice# WellID# <br /> EHO aa-0S raised QIV18 �/_ WELL/PUMP PERMIT <br /> L��/L 9ab'7 TO� <br />