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t <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)488-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS },.�/t l��//t ►/ML/��1�D� Y _ �(9��_—S Cmc y <br /> CROSS STREET APN)=0 U 100 <br /> 010 PMCELSQE �LAND USEAPPUCATKN0 ' <br /> OWNER NAME OU WWII PHONE F27—qV <br /> w <br /> OWNER ADDRESS f/ CITY/STATE21P N 3 w <br /> CONTRACTOR I C (� �P�H E 2Ef1 V /��2-2-- Iq <br /> CONTRACTOR ADDRESSWlfPW CMISTATEMP�YIQID, C quo <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE/IJP <br /> LICENSE C-57 D C-81 0 D-09 0 Other NUMBER `� EXPIRATION DATE <br /> DOMESTIC WELL SAMPUNG:0 General MineraUColiform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE C Domesbc/Private Inigation/Agricultural ❑Industrial 0 Water Qualtty Monitoring 0 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If dilWwt from 0— Watw System Name Cantaa Name or Phone Number <br /> TYPE OF WORK New Well 0 Replacement Well 0 Wes Atteretiott/Mndification 0 Other <br /> 0 onitoring Well(s) #of wells D Soil Boring(s) e of borings 0 Geotechnical a a boring• <br /> C Out-09-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement D Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rota 0 Air Rotary D Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well DepthM_ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter, In Thickness/Gauge/ASTM Schad� 0 Steel Plastic D Stainless Steel D Other <br /> Grout Seal Depth 'AO 0 Neal Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placemen Method Pumped 0 Free Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODImensions:Width ft Length ft Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible Turbine D Other HP Pump Set It 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 /> MI 48 HOAD EQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED .•r�� TITLE DATE <br /> F yMEN <br /> qN <br /> Vt aQ�� 8 ?0?1 <br /> RON V CO---4ti F- <br /> (/ <br /> DEp RTTq�Ty <br /> MENT <br /> DEPARTMENT USE ONLY �e <br /> Application Accepted By Date Area % Employee 1091 S <br /> Grout Inspection By �.)�-�j ., Date .� /:Y/'Z_ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check// Amount Date Penn1U Invoice/ Well IDS <br /> Codes Info Cash Remitted I I Service Request 0 <br /> EHD 41S-Oe aNtlte / /.(1� I/� �(/��� WELL/PUMP PERMIT <br />