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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAMILTON AVENUE-STOCKTON CA 95205-(209)488-420 <br /> NON-REFUNDABLE PERMIT,` CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS II_q�, N %AeLk{A RCRYZP Ll I Y► SITE m <br /> CROSS STREET Fra21-erJA. APN ObS 220-Ila PARCEL SIZE <br /> 3�-3�+ NO UUSE APPLICATION# o <br /> OWNER NAME Baa Lori La►ooriePyONE 3S1- I226 zn <br /> OWNER ADDRESS CITY/STATE/ZIP Ill AdY M <br /> CONTRACTOR M's-C114 'r\11iT�r[ PHONE 522- 1172-9 <br /> CONTRACTOR ADDRESS 1 l 1 r?the llS PA CITY/STATEIZIP edef 4o, 64 15367 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 66=2L— EXPIRATION <br /> � <br /> LICENSE C-57 0 C-61 0 D-09 U Other NUMBER EXPIRATION DATE y-36,-2-1 <br /> DOMESTIC WELL SAMPLING:❑General MineraUColiform Bacteria(4391)❑Dibromochloropropane(4392)u Arsenic(4393) <br /> INTENDED USE 0 Domestic(Private)(Irrigation/Agricultural n Industrial 0 Water Quality Monitoring U Soil Sampling/Characterization <br /> n Public Water System <br /> 11 ddferent from Ov r Water System Name Contact Name or Ph"Number <br /> TYPE OF WDRK X New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> C Monitoring Well(s) p of wells ❑Soil Boring(s) s or burl Vs ❑Geotechnical a of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> f;New Pump 0 Pump Replacement U Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method?(Mud Rotary 0 Air Rotary 0 Auger ❑Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth SW ft Excavation 2A/ 0 in diameter 0 Open Bottom KGrevel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter,LL in Thickness/Gauge/ASTM SchedU.2-So ?(Steel ❑Plastic I I Stainless Steel ;7 Other <br /> Grout Seal Depth 50 ft 0 Neat Cement(941b bag/5-10 gal wafer) XSand Cement ��._3 sack mix/7 gal water <br /> U Bentonite(20%solids) 0 Other <br /> Grout Placement Meth Pumped 0 Free Fall 0 Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller Pump Contractor D Other <br /> it Concrete Pedestal DDI ensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ❑SubmersibleC Turbine n Other HP Pump Set ft Standing Water Level fl <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WfTH 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 /> %RilAA1iM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)p953-7697 <br /> SIGNED TITLE DATE <br /> JAT 10 <br /> O��l�g4AA <br /> n <br /> ^� VI N T <br /> 5 I� T E <br /> DEPARTMENT USE ONLY <br /> Application Accepted By / '` Date it Ute' Area y %�f Employee IDAt %/1 <br /> Grout Inspection By 'EiA Date Z ❑ SPECIAL Well Pert111t <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date T� Constructed Wall Depth ft <br /> COMMENTS �eI� ji� it, >14V I L (i��.t 1�.�(F� UVI T�j��L�—ai'A L:"L , <br /> PE SC Received r4wkiW Amount Date PermiU Invoice i Well IDS <br /> Codes Info B Cash Remitted tt <br /> IU/ O 4 <br /> EH043-M a/01/16 <br /> WELL/PUMP PERMn' <br />