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I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS cn,r IP TouG a/ <br /> �r�–y/�t D <br /> CROSS STREET APN��UqO•�/ l O_PARCEL SIZE LAND USE APPLICATION <br /> 1#_ S <br /> OWNER NAME PHONE ti <br /> OWNER ADDRESS1 ' CITY <br /> C ` /STATEIZIP <br /> CONTRACTOR MMI� J 1 I I f`•' PHONE O r <br /> CONTRACTOR ADDRESSJkA CITYISTATEMP O VA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS _ CITYISTATEIZIP <br /> LICENSE C-57 D C-61 U D-09 ❑Other NUMBER l0 gll2ZEXPIRATON DATE 1 <br /> DOMESTIC WELL SAMPLING:Cl General Mineral/Coliform Bacteria(4391)U Dibromochloropropane(4392)U Arsenic(4393) <br /> INTENDED USE C DomesticJPrivate 5irligationlAgricultural C Industrial D Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water System <br /> It different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Xew Well ❑Replacement Well 0 Well Afteration/MOdification ❑Other <br /> O Monitoring Well(s) #of wells ❑Soil Bohng(s) N of borings ❑Geotechnical t or borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> C New Pump 0 Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodXMud to 0 Air Rotary U Auger ❑Cable Tool E)Push Point ❑ Other <br /> Proposed Well Depth R Excavation-� 11 <br /> �in diameter 11 Open Bottom D Gravel Pack/Gravel Size' In diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter. in Thickness/Gauge/ASTM Sched�_ ❑SteelPlastic a Stainless Steel 11 Other <br /> Grout Seal D pth ft C Neat Cement(94/b bag/-10 gal water) Pand Cement sack mix/7 gal water <br /> gBenlonite(20%solids) G Other <br /> Grout Placement Method umped D Free Fall C Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑Pump Contractor D Other <br /> C Concrete Pedestal DDimensions:Width It Length ft Thick in ❑Christy Box U Stove Pipe <br /> PUMP U Submersible Turbine D Other HP Pump Sel It 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 /> M M 48 HOUR <br /> SA NCE NOTICE REQUIRED FOR INS CTI S-PLEASE CALL(209)953,-1797 <br /> SIGNED S�`�- TITLE IVYDATE <br /> �q M <br /> F E��IVT <br /> V EO <br /> 20?0 <br /> H / Qui <br /> COO <br /> IV <br /> I till W, <br /> T MENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted Byr– ��— DateI .3 11 Area < < Employee ID# <br /> Grout Inspection By yI v Date MLI ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date -, Constructed Well Depth ft <br /> COMMENTS Vis•,.. i( N 'Lp 19or1 i,'nC x'� X111 nQ7J C I , <br /> 1 <br /> PE SC Received Check#/ Amount Permit/Codes Info B – Cash Remitted Data Service Re uest!! Invoice# Well ID# <br /> n I -- <br /> I <br /> EMO 4}08 &U 1118 � /' � I�J ��� WELL!PUMP PERMIT <br />