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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 />IVIJIV-KEFUNDABLEE rEERMrT <br />GALL ZUy 9,t1 -/by/ FOR INSPECTIONS tAYIKtb YEAR FROM LiAT7E ISSUED <br />JOB ADDRESS I <br />Vodesinfo <br />/ G/ <br />7v L . <br />1 ) I <br />�1C <br />{l <br />CITYlZ1P7 LV L <br />n✓ <br />CROSS STREET <br />�lJ <br />^ O <br />v�y, <br />APIN 1 V��1 �y�I�t41 _ <br />�jj�l� <br />J''Ut V PARCEL SIZE �'y LAND USEAPPLICATT�IIO1/N��# <br />A`�l <br />OWNER NAME <br />N� <br />�t <br />\ IA <br />0 <br />'P/ r 1 V ­ ' `l W <br />{//r��j]r <br />IO -� 1�__ PHONE ✓Oq � V O ' 1-� % Q <br />�I( <br />OWNER ADDRESS I lCIO <br />0 <br />N <br />CITY/STATEIZIP 1 <br />CONTRACTOR <br />S 1 II <br />�/ <br />INC/ <br />�% r�j ��J� <br />PHONE <br />�j� `�JL�(�I � 21 ' <br />CONTRACTOR ADDRESS IN <br />y1 �f� <br />CITY/STATEMP <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CrrY/STATEMP _ <br />LICENSE C-57 D C-61 0 D-09 <br />D Other <br />NUMBER 101 gtDZZ EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: F1 General Mineral/Coliform Bacteria (4391).0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE NornestictPrivate D imgalion/Agricuftural ❑ industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If dilleranl from Owner Water System Name Contact Name or Ptwne Number <br />I <br />TYPE OF WORN New Well D Replacement Well C Well Afteration/Modiftrabon D Other <br />U Monitoring Wallis) # of wells G Soil Boring($) s of bodrgs G Geotechnical t of bonnan <br />❑ Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />D New Pump D Pump Replacement C Pump Repair 0 Raise Well CasingP <br />WELL CONSTRUCTION <br />Drilling Method )<Mud Rota D Air Rotary G Auger D Cable Tool D Push Point 0 Other , V <br />fV <br />Proposed Well Depth ft Excavation �_ In diameter D Open Bottom C Gravel Pack/Gravel SizfT: n� tCe <br />D Conductor Casing in diameter / Conduct r Casing Depth ft <br />Well Casing Diameter. in Thidmess/Gauge/ASTM Sched � C Steel Kplastic 0 Stainless Steel ^ Other <br />Grout Seal Depth ft D Neat Cement (94 Ib bag/5-10 got wafer) ❑ Sand Cement sack mix/7 gal water <br />XBentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped D Free Fall U Other G Retardant 1 Accelerator (name) <br />PEDESTAL Installed By O Driller 0 Pump Contractor D Other <br />0 Concrete Pedestal DDimenslons: Width ft Length ft Thick in ❑ Christy Box n Stove Pipe <br />PUMP 0 Submersible Turbine ❑ Other HP Pump Sel 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 />7111= ADVANCE <br />NOTICE REQUIRED FORINSPEJ�IONS� PLEASE CALL (209) 953-X697 <br />SIGNEDTITLE / 1'11u1 14 IV i�' 2 <br />DATE ( <br />DEPARTMENT USE ONLY <br />CVJ I <br />Application Accepted By Date Area y /CCI Employee ID# <br />Grout Inspection By Dale ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring ZInspection By Date Constructed Well Depth ft <br />COMMENTS LXl� ll',; W�21i y-eM/,jn< <�� r/ciE' p�yhnlj t< Vii/ 1 <br />1? <br />ScReceived <br />B <br />Check#/ Amount <br />Cash Remitted Date <br />Permit/ <br />Service R uest # Invoice # Well ID#I,x <br />Vodesinfo <br />/ G/ <br />7v L . <br />1 ) I <br />�1C <br />J A I <br />..... r... W-•••- ��L'�w I. --fJ 2e V//1� WELL IFVMP PERMIT <br />Ln <br />M <br />D <br />0 <br />M <br />H <br />