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WELL/PUMP PERMIT <br /> SA a JGA,.1Jl1f Cowry ENVIRONMENTAL HEALTH DEPARTMENT tau EAST HAZELTON AVENUE-STOCKTON CA 95205-8232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WAIM.Sj9OV.Org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> X35 M �m�ph� Trim <br /> �JoeADCREss (� 1 j'� l,,(� Clrc�iP <br /> VCROSS STREE 7�0. �!n J APN_j.�C)70— -j C+ PARCEL SIZEro r LAND USE APPLICA lON 4 I T <br /> S('�� i <br /> � lr�t OWNER NAME -1 (-L'u S,:h. 1 D is tK J i 93C- PHOrN�E N(Jr n (yc2 .vP <br /> OWNER ADDRESS �� /�1 •� �rl.Uf-� CITYISTATEiZIP Tf IFI, ,1 f�1 l�+yJ,� }��1� <br /> CONTRACTOR �t ^�2 j�(1lit r t 'Dy-. <br /> / PHONE (.2y4)-i O� l -M <br /> (CONTRACTOR ADDRESS , v'�I\I1 (V,r`I,r t/ '^Y 1✓' • `C /f,� CITY/STATE:ZJP Gay�I Crt 1SL-3Z i <br /> SUBCONTRACTORICONSULTANT (;Lit W1, - -J' 1I V `1{�y�r�,11V U�""1 - PHONE (q 1 b 4ij - N 3 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS A,)-50 T ij�J' • I6`1 P" <br /> I . CITY/STATEl-7JP UjC��. vac- Ce 11 ®/ <br /> LICENSE ✓C-Si C-61 -D-09 _Other NUMBER <br /> OQU EXPIRATION DATE <br /> BILLING PARTY: OWNER _CONTRACTOR /SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE =Domestic/Private Imgation/Agricultural -Industrial C Water Quality Monitoring oil Sampling/Characterization <br /> C 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 /> Monitoring Well(s) #of wells Y Soil Borings) ;9)f bonngs Geotachnical N A bo..gs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connectlon Repair <br /> New Pump Pump Replacement _Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary 'Air Rotary **'OA'u g e r Cable Tool C Push Point - Other <br /> Proposed Well Depth 1_ft Excavation in diameter -Open Bottom Gravel Pack,'Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched -Steel =Plastic C Stainless Steel =:Other <br /> Grout Seal Depth l5 ft 3.10eat Cement('94!b bag 5-10 gal wafer) -Sand Cement sack nix/7 gal water <br /> Bentonite(20%solids) =Other <br /> Grout Placement Method :1 Pumped _Free Pall eOther -w*qfte I eta n ccelerator(name) <br /> PEDESTAL Installed By C Driller Pump Contractor C Other <br /> Concrete Pedestal-Dimensions:Width ft Length ft Thick in _Christy Box C Stove Pipe <br /> PUMP Submersible?Turbine a 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 /> MINT 48 HOUR^%eDVAN-CE NOTICE REQUIRED FOR INSP TIONS-PLEASECALL(209)953-7697_ <br /> SIGNED / `' TITLE 114"� DATE 51 l �L 1 <br /> "AlIkA all <br /> I <br /> 'I C)NIVI <br /> � I <br /> DEPARTMENT USE NLY /1 <br /> Application Accepted By Z�Z— Date a� a Area S r Employee ID# <br /> Grout Inspection By _ Date SPE AL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Rec ' e Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info s RemitWd I I Service Request# <br /> 37a I 15-13 11 r <br /> oa <br /> I � <br /> E—r 1],d iM T12Ct9 WELL'1`1,44P TERMIt <br />