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WELL/PUMP PERMIT <br /> ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� � CITY2IP Imo\ Cl <br /> CROSS STREET ^ ^APN ✓ 1 C)I"O'V PARCEL SIZE '41�7 LAND USE APPLICATION# p <br /> C 11�1 I C - m <br /> OWNER NAME (�(�(7���n7 \ /^,+ PHONE r^. <br /> OWNER ADDRESS 1)V J O ,� �I V`� C O CITY/STATE2JP I/l 1 <br /> CONTRACTOR ` I / I I G" 11�r1P`HONrE'r r�,�l '�] a4��Ij I�U <br /> CONTRACTOR ADDRESS III / 1 I S CITYISTATE/LP M W^ N I r/ Ca 1 C/Sf <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYISTATE/0P <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Othet NUMBER nL - ExPIRATON DATE <br /> DOMESTIC WELL SAMPLING:• General Mineral/Coliform Bacteria(4391)l7 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural C Industrial 0 Water Quality Monitoring C Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK L New Well Replacement Well D Well Alteration/Modification 0 Other <br /> Monitoring Wells) #of wells 0 Soil Boring(s) 0 of bongs 0 Geotechnical 0°f bonngs <br /> C Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement D Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rota 0 Air Rotary 0 Auger Cable Tool �!Push Point G Other <br /> Proposed Well Depth Q it Excavation Q2 In diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Cond c r Casing Depth It <br /> Well Casing Diameter Ll In Thickness/Gauge/ASTM Sched [ Steel 0 Plastic C Stainless Steel 11 Other <br /> Grout Seal Depth _ft C Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> XBentonite(20%solids) C Other <br /> Grout Placement Method Pumped ❑Free Fall 0 Other 0 Retardant I Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑Pump Contractor Other <br /> 7 Concrete Pedestal ODimensions Width fl Length ft Thick n [Christy Box ❑Stove Pipe <br /> PUMP U SubmersibleC Turbine ❑Other HP Pump Set it Standing Water Level <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 COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR A VANCE NOTICE REQUIRED FOR IN PEC I�Q NS-PL ASE CALL(209)953-7/6,97 1 <br /> SIGNED TITLE I�1'1► j U�r� DATE <br /> I Hum <br /> RFq yM <br /> 4AR <br /> ha CoCN�rl <br /> I <br /> / Q TMENT U E N�LY <br /> Application Accepted By L1 I Date `—� Area Employee ID# <br /> Grout Inspection By Data <br /> 1 ❑ PECIAL W@II Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins pact i`D-n.By Dated Constructed Well Depth f< <br /> COMMENTS �dR `l O�Q 1�1� f:f.1SIY�LI Z {, AroUt'IA�' <br /> PE SC Received CtweldJ Amount Date Perm Invoice# Well ID# <br /> Codes I o Remitted Service R oast <br /> EMD 43-M 8f01/1E �2-3 9-2 �., �}T WELL(PUMP PERMIT <br />