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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11 N <br /> JOB ADDRESS I1goo Al UtL c{ ti2a CRYlLP_LI NOI•rHl, ir4 9S2I6 _ rn <br /> f 1 D <br /> CROSS STREET Fra21-Cr �• APN ObS'220-I10 PARCEL SIZE 1,J�IDLAND USE APPLICATION# o <br /> 1 -i A — z <br /> OWNER NAME Bnr ( Lobi Lw rt O PVONE 3S I' I Z(,.c.! rn <br /> OWNER ADDRESS 'L0001 f, 't�D � CITY/STATE/ZIP LI `1"dy M, 1 5,;U( <br /> CONTRACTOR M OLS-ell;jAJ)r111l1-.21 . PHONE 1S2,Z- J9Z8 <br /> CONTRACTOR ADDRESS I I 1 Al j be�J " CITYt$TATE/Z1P Od k,T TG/ CA 1s 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Crry/STATFJZJP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER b6t43r ,Ci ExPIRATION DATE 41-3&-2-1 <br /> DOMESTIC WELL SAMPLING:11 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)U Arsenic(4393) <br /> INTENDeO USE ❑Domestic/Private)(IrrigatioNAgricultural ❑Industrial n Water Quality Monitoring ❑Soil Sampling/Characterization <br /> C Public Water System <br /> Ir <br /> diff—t Iron Owner Water System Name Contact Name or Pt—Number <br /> TYPE OF WORK X New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #Of Wells 0 Soil Boring(s) s or boring' ❑Geotechnical 0 of Wnngs <br /> 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-COnnectlon Repair <br /> D New Pump 0 Pum Re-placement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool C Push Point C Other <br /> Proposed Well Depth 0P p J�_ft Excavation�in diameter 0 Open Bottom )(Gravel Peck/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameler,L�6_in Thickness/Gauge/ASTM Schedy2S0 (Steel ❑Plastic U Stainless Steel n Other <br /> Grout Seal Depth 50 ft ❑Neat Cement(94 lb bag/5-10 gal water) �V Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Metho Pumped ❑Free Fall 0 Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller Pump Contractor ❑ Other <br /> 17 Concrete Pedestal DDlfnenslons:Width_11 Length ft Thick in ❑Christy Box U Stove Pipe <br /> Pu MP :7 Submersible Turbine ❑Other HP Pump Set ft Standing Water Level ti <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 COMPLJANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> yM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)g953-7697 <br /> SIGNED TITLE G V">1.0 DATE <br /> VEC <br /> VI N <br /> A T E T <br /> DEPARTMENTnUS ONLY <br /> Application Accepted By - ��'- Date ! ° Area Employee IOIY <br /> Grout Inspection By Date ❑ 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 Deb Permit/ <br /> Codes WeIIID# <br /> Codes Info B Cash Remitted 1 Request 3 <br /> EHD 4SO6 8101/10 WELL/PUMP PERMIT <br />