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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ( � n CALL 209 953-7697 FOR INSPECTIONS r(JE�IXPIRE(S�1 YEARFROMDATE ISSUED <br /> JOB ADDRESS J )W FI2 '^'V V CITY/LP I'FK V "A �"`S0 m <br /> qqCROSS STREET LO ' / APN I _) 7- V ZCARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME 9A-<,An A C—I L)Ol n __ PHONE( /� /� /'� <br /> OWNER ADDRESS aQb6 7 AL I�P iat - CITY/STATE21PP�%/ CA '/5'3VG/ <br /> CONTRACTOR AGfa,//,+C zwt ,p�y'I���C�V]yjP�.r tdd[ P/H�O,NNE�I'7�ly�j?'o 106 / <br /> CONTRACTOR ADDRESS,y�/7J E CJrYr"'y"'� `-� `�'" CITY/STATEMP � ✓CA/�,/{o(/L 9ly / <br /> SUBCONTRACTOR /V/'4 h /PHONE 'V0 <br /> SUBCONTRACTOR ADDRESS f-l� CCIITY/STATEZP /VA <br /> LICENSE AC-57 0 C-61 ❑D-09 ❑Other NUMBER /5->7(7 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> New Pume 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth it Excavation in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 6TPump Contractor 0 Other <br /> Concrete Pedestal❑Dimensions:Width_,�_ft Length ;r ft Thick 42 in 0 Christy Box 0 Stove Pipe <br /> PUMP Submersible❑Turbine 0 Other HP 5J Pump Set ft Standing Water Level 6y 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 /> MI IMUM 48 H V �E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE DATE. <br /> �i` DATE {y (G <br /> A U <br /> N E <br /> R <br /> DEPARTMENT US ONLY <br /> 1, �� Date ti `�' 13 0l <br /> Application Accepted By ) � Area Employee ID# <br /> Grout Inspection ByDate ❑ SPECIAL Well Permit <br /> Pump Inspection By, pL�Date -1,����I,\ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> i <br /> PE SC Received h Amount DatePermit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> 0 <br />