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ENTAL HEALTH DEPARTMENT PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468-3420 <br />SAN JOAQUIN COUNTY ENVIRONM <br />NON-REFUNDABLE PERMIT <br />WWW.S, Ov.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CITY/Zip o? <br />CROSS STREET��j'/ d� APN�j lJ� ✓ �- D <br />PARCEL $IIE1� J � LAND USE APPLICATION # � <br />OWNER NAME <br />Z <br />D <br />:c� y9 �� A <br />OWNER ADDRESS C) PHONE NE- -J _ <br />.v CITYISTATEIZJP L(,/C�l / I SZ <br />CONTRACTOR Y iY1cC.v��� �rx-�- �� S u ` .��A � � n C.., PHONE <br />+ <br />CONTRACTOR ADDRESS 220 (.l� / � . C <br />/-T <br />I � ` �UCid CITYISTATEIZIP_ m/�.9�J•%I.S <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS -- <br />CITY/STATEIZP <br />. <br />LICENSE Tc C-57 C-61 t: D-09 J Other QQ <br />NUMBER gU99.1��1C_ EXPIRATION DATE I 7 7 <br />BILLING PARTY: OWNER <br />- CONTRACTOR J SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE ^LJOmestidPnvate - Imgation/Agricultural -Industrial _ Water Quali Monitonn <br />- Public Water System tY 9 Soil SamplinglCharactenzation <br />If olifferent from Owner Writer System Name <br />Contact Name or Phone Number <br />TYPE Or WORK - New Well - Replacement Well -_ Well Alteration/Modification <br />Monitoring Wells) Other <br /># of wells Soil 60nng(s) # of borings <br />Out -Of -Service WellGeotechnical 4 of borings <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />- New PUT 0 SlPump Replacement - Pumn P.—ir <br />Drilling Method - Mud Rotary Air Rotary _ Auger - Cable Tool _Push Point : Other <br />Proposed Well Depth h Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />LGrou- Conductor Casing in diameter / Conductor Casing Depth ft n diameter <br />t <br />l Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />out Seal Depth ft Steel _ Plastic Stainless Steel - Other <br />Neal Cement (94 /b bag/$ -10 gal tvater) Sand Cement <br />Bentonite (20% solids) _ Other sack mixt% gal water <br />Placement Method -Pumped - Free Fall Other <br />- Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller --Pump Contractor _ Other <br />Concrete Pedestal Dimensions Width It Length fl Thick n <br />Christy Box Stove Pipe <br />PUMP j',Submersible Turbine Other Hp <br />L Pump Sel R 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 />CURRENT <br />N 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 LAW <br />I.'iNl <br />SUR • C�lE�7NOTIIICCE REQUIRED FOR INSPECTIONS - ;-LEASE CALL (209) 933j'Fe-- <br />SIGNED L'.% 'l ! '��� TITr <br />Application Accepted By L�L� Date! Cj CI <br />Area Employee ID#tjA <br />Grout Inspection By Dale <br />SPECIAL Well Permit <br />Pump Inspection By Date � ' % O �� <br />WAIVER Received <br />_. <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth R <br />V/ELL rPUMP PERMI T <br />