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�NWELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> (� NON-REFUNDABLE PERMITWWW.sj9ov. 1910d EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ' ( �� l.. � _ _ CITVIZIP_ i <br /> CROSS STREETFrench 1 R APN 1?04001 PARCEL SIZE 2I�LAND USE APPLICATION# 09 <br /> a VJ 'I �-- - r? �j In <br /> OWNER NAME (J a '�_ I I7^7I rn7LG��l� _` `� w <br /> OWNER ADDRESS Z Z Z Lk (A 1^ �,t c _ CITYl"AlATEC `-� L t <br /> J-3CONTRACTOR r L C. PHOCONTRACTOR ADD�q� 1.1 CITY/STATE/ZQ S <br /> SUBCONTRACTOR/CONSULTANT HONE <br /> SU13CONTRACTOPJCONSULLTAANT ADDRESS I V tfl (:.ITYYIr7STAT'E//ZIP h W 1 1 <br /> LICENSE C-57 ✓�,C-61 D-09 Othe V� NUMBER / �W P(/ EXPIRATION DAT ` e,X'\ <br /> BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WEIRSAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> j - <br /> INTENDED USE ^Domestic/Private Irrigation/Agricultural— Industrial —Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System_ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #ofv"SE's Soi!BCGry(c) ttetb<winys Ganiechricai Aa'bongs <br /> Out-Of-Se Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing _in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth_ _ft Neal Cement(94 lb bag6-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width—ft Len Ih ft Thic in Christy Box S ove Pipe <br /> PUMP ubmersible Turbine Other HP Pump Set It Standing Water Level it <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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FTI�INJJSP�EECTTIQON�S/�-PLE/AISE CALL(209) 54-7697 <br /> SIGNED TITLE I r ��C !/ t��1/1 DATE V 1 <br /> _ F yMFN <br /> I � <br /> N 24 2�?1 <br /> JQU//V <br /> I � E qih <br /> RTo �NTy <br /> - MFNT <br /> 3 / DEPARTMENT USE ONLY //�/ <br /> Application Accepted By —Z-70L-L, Date d y d I Area Employee ID# A V <br /> Grout Inspection By_ Date SPECIAL Well Permit <br /> Pump Inspection B Date_ WAIVER Received <br /> J <br /> Soil Boring Inspection By_ Date _ Constructed Well Depth _ ft <br /> COMMENTS <br /> PE Sc Received Check# Amount Permits <br /> ¢C'odes Info B as Remitted ata S rvice Invoice# Well ID# <br /> 'T S <br /> I <br /> EHD 43-06 6111/1019 WELL/PUMP PERMIT <br />