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yminq% ou IIG Z <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95206-(209)488-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSftk�pluCITY/ZIP i2!'YI 11, Olb N. rl6u <br /> CROSS STREET W APN�191 FIA 1V—PARCEL SIZE_LAND USE A�(PPILICATTIIIO(N <br /> { 11 <br /> [ d F <br /> OWNER NAME 1„ Gloria PHONE 2,�J � ,/V.NV/�f—r;JJ�rI <br /> OWNER ADDRESS CIT'/STATE/Z1P 1 T I� S,(A <br /> CONTRACTOR fflmI JC prillin MIC �PHONNED' I (�'7 <br /> CONTRACTOR ADDREss I /l` CITY/STATEIL ]O1/W <br /> P r•r Q J/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEILP <br /> LICENSE C-57 ❑C-61 D D-09 0 Other NUMBER l01>9Rf02Z ExpiRATION DATE'y.2—' <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliforrn Bacteria(4391)u Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 0 DomesWPrtvate rrigation/Agrkxrftural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Charactenzation <br /> 0 Public Water System <br /> H delemd from Owner Water Systa.Name Contact Name w Phone Number <br /> TYPE OF WORN New Well ❑Replacement Well D Well AlterationfModification C Other <br /> 0 CE A I <br /> dV�onfloring Well(s) N of walla ❑Soil Boring .of bonrp.s) ❑Geotechnical a b;na. <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> D New Pump 0 Pump Replacement D Pump Repair D Raise Well Casing <br /> 7 <br /> WELL CON3TR <br /> Drilling Method Mud RM Air Rotary 0 Auger 11 Cable Tool El Push Point 0 Other N J 20` <br /> Proposed Wall Depth _ft Excavation JA—in diameter ❑Open Bottom D Gravel Pack/Gravel Size �ONI (6S NDN COON r <br /> D Conductor asing in diameter / Conductor Casing Depth ft TF1 F;1FN r, <br /> Well CasingDiameter Thicknesa/Gauge/ASTM Schad 1 Steel ❑Plastic D Stainles Stt I Li Other R i„�NT <br /> Grout Seal Depth 30 ft 0 Neal Cement(94 lb bag/5-10 gal wafer) Sand Cement % sack mixf7 gal water <br /> ❑Bentonite(20%solids) C Other <br /> Grout Placement Method Pumped 0 Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> FftpE;ITA Inatalled By 0 Driller 0 Pump Contractor ❑ Other <br /> 0 Concrete Pedestal ODlmanslons:Width it Length ft Thick In ❑Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible❑Turbine ❑Other HP Pump Set R Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> M M 48 H_QUSApO NOTICE REQUIRED F1 SPE o4hNS-PLEASE CALL(209)9 3-76 7 <br /> SIGNED "r� (/ TITLE n�V DATE w <br /> IF <br /> DEPARTMENT USE ONLY <br /> Application Accepted By - Date `1 X LA Area � � Employee IDt <br /> (,rout Inspection By Date ❑ SPECIAL Well Perrnit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By D to I{Constructed Well Depth h <br /> COMMENTS 10' �'`x-r Il 1s 1-,x_r't NC �� _�1'S�L {Il� t f✓!-, <br /> T <br /> PE SC Received Chaclti! Amount Dat ParmW Invoice N Well IDS <br /> Codas Into Cash Remitted Service Reauest/ <br /> 3E�; v Oma— •1 <br /> ila�41 TV <br /> EH043-0e M1116 //�� ' 1233497q.2- WELL RUMP PERMIT <br />