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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 />NUN -REFUNDABLE PERMIT <br />(209 95533-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />I 7,� D O <br />/CJALL <br />�J yaok,, / r? O CITY/ZP <br />TM/jG �/ / S r✓G� <br />CROSSSTREET <br />�f� <br />APN PARCEL SIZE <br />LAND USE APPLICATION�# <br />OWNER NAME <br />A&ZZ <br />PHONE(YO✓) F% - /1'7 / <br />OWNER ADDRESS <br />71 9e4vdyea.,,to., <br />CIN/STATE21P <br />7Q /'4 --?0x <br />CONTRACTOR <br />GOL OAF,.i <br />S-J'a ?-if AHK ��✓Mli <br />, <br />PHONE C'/ 7,7 <br />CONTRACTOR ADDRESS %SOO J°-��2E• .��/�e�-✓�r7 ��' CITY/STATEMP <br />s -r -, 9C.71-4 <br />SUBCONTRACTOR <br />�,/ /1/ <br />PHONE <br />SUBCONTRACTOR ADDRESS _ /V CITY/STATEMP <br />LICENSE 7 C-57 k) C-61 ❑ D-09 C Other NUMBER q 7qL;-Z3 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) L Arsenic (4393) <br />INTENDED USE ,WDomestic/Private ❑ Inigation/Agdcultural ❑ Industrial D Water Quality Monitoring 7 Soil Sampling/Characterization <br />1 Public Water System <br />If different from Owmec Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well )Replacement Well 7 Well Alteration/Modification _ Other <br />G Monitoring Well(s) # of wells 7 Soil Boring(s) 4 of borings 0 Geotechnical A of borings <br />-1 Out -Of -Service Well -1 Out -Of -Service Well Renewal F Cross -Connection Repair <br />Drilling Method r, Mud Rotary Air Rotary Auger Fi Cable Tool Push Point n Other <br />Proposed Well Depth ft Excavation in diameter C Open Bottom D Gravel Pack/Gravel Size In diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic U Stainless Steel 17 Other <br />Grout Seal Depth ft u Neat Cement (94 Ib bag/S-10 gal water) L Sand Cement sack mix/7 gal water <br />L Bentonite (20% solids) L Other <br />Grout Placement Method -7 Pumped L Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller a Pump Contractor L Other <br />C Concrete Pedestal ODimenslons: Width ft Length ft Thick in 0 Christy Box Stove Pipe <br />PUMP ubmersibler" Turbine n Other HP ---:7— Pump Set 6 ft Standing Water Level R <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 />IVIINIINUIU 48 HOU=ADY,41-0 <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 �J <br />SIGNED— - TITLE ! 4 / ?'1 14 6 e DATE (� -1y ^/ <br />1'r <br />s -I <br />co <br />MENTe <br />DEPARTMENT USE ONLY <br />Z <br />/ <br />Application Accepted By Z L- Date <br />Grout Inspection By // Date <br />Pump Inspection By L%I C S(� l�,r.-�y Date 1 /-7 Liu i <br />Area Employee ID# t"! <br />7 SPECIAL Well Permit <br />:] WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS j#eC vJ 0 i I Irl PC) r i (,Ci d <br />EHD 43-06 revised 4114118 WELL tPUMP PERMIT <br />