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i41 cz� �g n��ial a/i ib <br /> WELL/PUMP PERMIT <br /> SAN JOAQUiiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NJPJ-REF3NDABLE PERMIT CALL 209 99553y-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> l ADDRESS _ ` �' �+�1 to <br /> � CITY/ZIP k. /T/T ,1 )` r� m <br /> CROSS STREET AP4W) r PARCEL SIZE 15' LAND USE APPLICATION# o <br /> OWNER NAME f 1 PHONEOn <br /> OWNER ADDRESSY M �1 CITY/STATE/ZIP W t -i-0 `-// t �j(nq'� <br /> CONTRACTOR \ 1,L WELL� C II CI�v /^PH+ON m 6— <br /> CONTRACTOR ADDRESS pci, CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER __? EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well ❑Replacement Well [-]Well Alteration/Modification ❑Other <br /> ❑ onitoring Well(s) #of wells [-]Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump Ej Pump Replacement El Pump Repair E]Raise Well Casing <br /> WELL CONSTRUCIION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger Cable Tool E]Push Point El Other <br /> Proposed Well Depth��41n Excavation in diameter E]Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conduc r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ofj _ 6 Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) and Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method XPumped ❑Free Fall E]Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑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 /> MINLIALM4 HOUR A.D,YANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)/9/53-7r697 //� <br /> SIGNED `!� TITLE "U DATE `(" / t6 <br /> ^1 <br /> J pr <br /> H N M Y <br /> � M <br /> D PARTMENT USE ONLY /� <br /> Application Accepted. Date (( I ZO b Area "Y Employee ID#��17 <br /> Grout Inspection By �.�s Date ! l / ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/ <br /> Date Invoice# Well ID# <br /> Codes Info B sh Remitted Service Request# <br /> 1p--7 00 "A di' ' , F <br /> FHD43-06 WOV-6 `.'JELL/PVAAPPDi '.tli <br />