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R ' WELL/PUMP PERMIT SAN JOA WIN COUNTY EMARONAENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)488-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ d EXPIRES//I��YEAR FROM DATE ISSUED �j� JOB ADDRESS c -e-r T. L f z�j CROSS STREET _`Lc�c7 I C/ APN 31-4 PARCEL SIZT��dI1ID USE APPLICATION# O OWNER NAME 1 Y l �`��//"�V`li LL. PHONE\'O 7J� \ N OWNER ADDRESS- r ( k L-> O �� p CITY/STATE21P k'I C�`� 1�'�l yGJ(C�(�/S CONTRACTOR I I r ". Y( �( C�'t r V �✓1 V PHONEE V `�i CONTRACTOR ADDRESS SUB CONTRACTORICONSULTANT PHONE SUB CONTR ACTORICONSULTANT ADDRESS CITYfSTATFJZIP LICENSE )(C-57 ❑C-61 0 D-09 0 Other NUMB-Ott EXPIRATIONDATE BILLING PARTY/ Il OWNER E.CONTRACTOR n SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)n Arsenic(4393) INTENDEDUSE Domestc/Private 0Irrigation/Agricultural 0Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization Public Water System If dMerenl from Omer. Water System Name Contact Name or Phone Number TYPE OF WORK -1 NeW Well D Replacement Well U Well Alteration/Modification 11 Other 0MonitnringWell(s) #of wells 0 Soil Bonng(s) sofbOeeBs CGeotechmcal eofbonngs ❑Out-Or-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pump Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTldN Drilling Method 0 Mud Rotary ❑Air Rotary 0 Auger 0 Cable Tool ❑Push Point 0 Other Proposed Well Depth ft E XC2Vahon in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter Cl Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic D Stainless Steel ❑Other Grout Seal Deptn tt !I Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack m1rl7 gal water ❑Bentonde(20%solids) U Other Grout Placement Method ❑Pumped ❑Free Fall 0 Other 0 Retardant/Accelerator(name) PEOEsrAL �Ln/sfailed By 0 Driller Pump Cordract 0 Other �n Concrete Pedestal:1Dlmenalons Width ft Length ft Thick in rl Christy Igo. rl Stove Pipe PUMP Submersible Ll Turbine ❑Other HP= Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M)Ki, ld. 8 H UR V�NOTICE REQUIRED 7; I^Ic.a^ TtOfl; -F..F_AcE CALL(20 1 ar 'rc-' SIGNED (%/' �� TITLE 03 ; QUII y COUNry / E/PAR TM ENT USE ONLY Application Accepted By <� Date /Z J-" t1 00%rea s Employee ID# e, MFNr Grout Inspection By Date ❑ SPECIALWell Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring I pec[ion B 1r gatef �Conr��uct)ed ell� th�h TTV COMM ENTS � •�U/ I/A�ti ilfn is — 1-1 —L�.�- PE Sc Received Check#/ Amount D to PermlV Invoice Well IDII Codes Info B cash Remitted rvlce R ue t p0 1 A& / L r r , EHD 11,11 1/1111/11 WELL/PUMP PERMIT