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WELL./PUMP PERMIT SAN JOAOUIN COUNn ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 466-3420 NON-REFUNDABLE PERMIT CALL (209} 953-7647 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ADDRESS SS STREET_ IER NAME IER ADDRESS ADDRESS ADDRESS 1\�✓ 1 (Jlu�{i' _%�j�__ ClntzlP 'J�UVrj,SiN. (iW -tbGl'''7 -" O� � ^ n APN �'l}1�� -��}�O � aV(�� PARCEL SIZE �' � LAND USE APPLICATION # a�j]�j U. V t V - 11� �V - � PHONE �O� • �/JO � t''1_-'7"/1 1 (�'' CIn/STATE/ZIP _G Vrt � 1 /Q� 1� I � � � � 1 V PH��ON��%Err�rr^^ � �f) ��J�j��'I 1C.,%�' CIn/$TATEIZIP,�(,� j� Gt�i/ � %� (/ I PHONE CITY/STATE2IP C-57 D C-61 D D-09 ❑Other NUMBER �,]�� EXPIRATION DOMESTIC WELD SAMPLING: d General Mineral/Coliform Bacteria (4391�.E1 � ^ Dibromochloropropane (4392) D Arsenic (4393) INTENDED USE DomestiGPrivate D Irrigation/Agricultural ❑Industrial D Water Quality Monitoring D Soil Sampling/Characterization ❑ Publ(c Water System � ^ Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑ Cahie Tool ❑Push Point ❑ Other ^I tt Proposed Well Depth ft Excavation �_ in diameter It dilteront from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well ❑Replacement Well ❑ Mon(todng Weil(s) # of wells ❑ Out -Of -Service Well ❑ New Pumo ❑Pumo Replacement D Well Alteration/Modification ❑Other ❑ Soil Borings) MOtbOdr'g' D Geotechnical D Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ PUr11D Repair ❑Raise Well Casino N of borings WELL CONSTRUCTION t�' �� /J/�.'.��%�.��L��Q�I�L�'��Etic��l� � ^ Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑ Cahie Tool ❑Push Point ❑ Other ^I tt Proposed Well Depth ft Excavation �_ in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in�d( to ❑ Conductor Casing in diameter / Conductor Casing Depth ft Wall Casing Diameter. in_ Thickness/Gauge/ASTM Schad �� U Steel .Plastic ❑Stainless Steel ❑Other Grout Seal Oeplh ft ❑Neat Cement (9416 6ag/5-10 get water) 0 Sand Cement sack mixR gal water Bentonite (20%solids) ❑ Olher Grout Placement Method Pumped ❑Free Fall D Other ❑Retardant /Accelerator (name) 0®� PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimonslons: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑ SubmersibleG 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �� t�ADVANCE NOTICE REQUIRED FOR INSPE j77jnn••''I��OpR'�NSQ- PPLEASE CALL (209) 953-77j6��9j7'� /� SIGNED _ �\ ��itt, TITLE��t)YYNB�. DATE �� v�' /�V� s Application Accepted By �--�`�� Groutlnspection By Pump Inspection By —� Soil Boring Inspection By DEPARTMENT USE ONLY Date �' yf� � l Date G'�- Data Date �C9'}t� L]r Ir �h� 1 Area Employee ID# �J ❑ SPECIAL Well Permit ❑ WAIVER Rece(ved �� Constructed Well Depth � �L/ n 7' 0 0 z N F Y��NT CF�V�� EB � y ?O?1 AQv�N p�pQRTM �NrY Nr �n.�: � lZc� �v� �� WELL rPUMP PERMIT t�' �� /J/�.'.��%�.��L��Q�I�L�'��Etic��l� � : : � - :. � . � � �►,��rr��r��r�� ��.i�i/K�.�l��d�'�III�R�ir �I�y�=�� 0®� !mai �� �n.�: � lZc� �v� �� WELL rPUMP PERMIT