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A, <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (2091468.942 <br />PERMIT <br />SIS <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME I <br />OWNER ADDRESS '2J <br />CONTRACTOR I <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR ADOREss <br />LICENSE kC-57 D "1 O D-09 ❑ <br />CALL (209) 953-7V FOR <br />IA 1, t <br />FROM DATE <br />rvt-A rfA• CrTyrZJPsj lIr_ `: IM &IV7U1kU <br />APN24� -' — PARCELSIZE LAN. USE APPLICATION <br />OUwla- PH.NE jM *';'I 1Yg4 �} _ <br />(� w1 CITY/STATE/LP N}`1W 6a <br />�1 � t- P ... EyA'. Lti 1°l1,00 <br />I J CITY/STATE/LP Mk)fk I CA grd;W <br />PHONE <br />NUMBER <br />CrTY/STATEZP <br />ExPiRATIONDATE _i dip' <br />DOMEsnc WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 DomestidPrivate lrrigation/Agricultural 0 Induslnal D Water Duality Monitoring ❑ Sail Sampling/Characterization <br />D Public Water System <br />Ilddl—t from Owner Water System Name Coitacl Name or Phone Number <br />TYPE OF WORK New Well 0 Replacement Well D Well Alterabon/Modificabon ❑ Other <br />❑ onitoring Weil(s) Sof wells 0 Soil Boring(s) e m bO^mg� 0 Geotechnical e m b—gs <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />u rump me lacement u rump rte air ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger Cable Tool D Push Point U Other <br />Proposed Wetl De th ft D ft Excavation In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Dlameler.]i in Thichness/Gauge/ASTM Sched UD D Steel Mastic ❑ Stainless Steel 0 Other <br />Grout Seal D pth_M_it ❑ Neat Cement (94 111 bag/ --f0 gal water) ❑ Sand Cement sack mW7 gal water <br />Bentonite 20% solids) [I Other <br />Grout Placement ethod Pumped ❑ Free Fall ❑ Other D Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />D Concrete Pedestal DDlmenslons: Width it Length R Thick in D Christy Box ❑ Stove Pipe <br />PUMP 0 Submersible❑ Turbine 0 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 />JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED UCENSEp IS� <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH At4 <br />WORKERS COMPENSATION LAWS. /v, <br />DEPARTMENT USE ONLY <br />Application Accepted By G,�G� Date F7 Area 7 Employee ID# <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring inspection By Date Constructed Well Depth ft <br />COMMENTS 7r) fbot SG 4 tie r' <br />MSCRecelvedChecks/ Amountpa�lU <br />Cash Remitted Date S rvlce R uest S Invoice S Well IDS <br />q1 jF0 <br />n r <br />P. f <br />--/rl iJ lJ 1 / r l O WELL muMP PERMIT <br />