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WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />CALL <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS IS IJU /I/iC <br />1 <br />�r�• <br />CITY/ZIP <br />ES,-nlu , CA J5320 <br />CROSS STREET caffb Iron1 <br />J <br />_i <br />•^ <br />✓ L� �/C;T PARCEL SIZE - <br />LAND USE APPLICATION # <br />r <br />�APN <br />ZjSS <br />OWNER NAME Y/�l�S <br />{YC <br />PHONE _ZC I_�Qo03Q' ] <br />jQFtLk <br />� <br />1 <br />ESCal c"l <br />OWNER ADDRESS 1 p r SL) b odd% <br />CITY/STATErLP <br />! <br />f <br />a, �r1.A /5-_J 77p <br />PHONE Z.D I I/1'/5 (0 <br />CONTRACTOR A nt <br />D <br />CONTRACTOR ADDRESS 1510 <br />^T' <br />•--1 <br />CITY/STATE/ZIP <br />•�(0 <br />/"L(i J1�P C� IA9h T-7 (a <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYI�STATE/ZIP <br />LICENSE : I C-57 C•61 r: D-09 <br />I I O01e( <br />Num BER I L -f 21 (O EXPIRATION DATE- 3 f li7i <br />DOMESTIC WELL SAMPLING: L I General Mineral/Coliform Bacteria (4391) . I Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE L DDmestici Private - IRlgalionlAgncultural I Industrial Water Quality Monitoring ; Soil Sampling/Charactenzation <br />O Public Water Sys em <br />If d,fl—ril Uam Owen; voter syslnm N.— C -1-t N.— m Ph— 'W I - <br />TYPE OF WORK I New bVMI i I Replacement Well (i Well AllerahonlModlficalion I I Other <br />I I Monitoring Well(s) # of wells ! Soil Bodng(s) IW h.Hng, I Geotechnical z of greys <br />I I Out -Of -Service Well ' i Out -01 -Service Wall Renewal ! I Cross -Connection Repair <br />)Vm..., P,- , P,- P --imam I Pum❑ Renalr I I Raise Well Casino <br />Drilling Method C Mud Rotary I I AT Rotary Auger I Cable Tool I Push Point I, OLner <br />Proposed Well Depth it Excavation in diameter I I Open Bottom i I Gravel Pack/Gravel Size In diameter <br />Ll Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/GaugeIASTM Sched I Steel i I Plastic I Stainless Steel Other <br />Grout Seal Depth ft I Neal Cement (94 Ib bag15-10 gal warer) -I Sand Cement sack mixR gal water <br />rl Bentonite (20% cofids) I Other <br />Grout Placement Method ❑ Pumped i i Free Fall I Other I Retardant I Accelerator (name)_ <br />PEDESTAL Installed By ❑ Driller I.; Pump Contractor t ! Other <br />i! Concrete Pedestal IlDimensions: Width ft Length tt Thick in i, Christy Box I I Stove Pipe <br />PUMP ' SubmersibleL Turbine i -I Other HP Pump Set 17 i % if Standing Water Level <br />I HEREBY CER*Y 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 WITVWS <br />LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMP SA /HCE NOTICE REQUIRED FOUR INSPECTIONS - PLEASE CALL (209) 953--76�Z97 <br />SIGNED � - J � TITLE YYLJ.:�v/ti E';✓� DATE Zj �1 1`' <br />�� MINT <br />Q>JlN <br />E N��NrY <br />R iv)- <br />DEPARTMENT <br />NT <br />DEPARTMENT USE .ONLY <br />Application Accepted By Date 3'la✓f Area Employee ID#Fill"', <br />Grout Inspection By Date I SPECIAL Well Permit <br />Pump Inspection By Date iiRE I WAIVER Received <br />Soil Boring Inspeo' n BY - Dale Censtrvcted Well Depth It <br />COMMENTS ',Af I I L'J` F0 <br />ENO 4--0 nand 111n 6 V/ELL IP•—P PERMIr <br />SII WIRANWAEMFIA�9191ER :►IMiffiflll�W <br />_ <br />ENO 4--0 nand 111n 6 V/ELL IP•—P PERMIr <br />