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z _ <br /> r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•STOCKTON CA 96205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �T P /1`' N <br /> JOB ADDRESS 1 V CrTY/Z1P o Q m <br /> D <br /> CROSS STREETMufpPIN 0;0Z PARCEL SIZE 26. LAND USE APPLICATION# z <br /> �1 m <br /> OWNER NAME 1�`In y���,y��� PH(O�NE AI /�. <br /> OWNER ADDRESS N/ 111 V 1� 1 prilliIb f'Pic CITY/STATEZP ►,Z)L AIDIN IyA W• �`7 J///y/� <br /> CONTRACTOR „l N v. PHONE 1'/�A�ZZ/��gie <br /> CONTRACTOR ADDRESSliftjK $1161CITY/STATE2,P l GA,lA, •"1 J�1 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRE53 CITY/STATE21P <br /> LICENSE C-57 0 C-61 ❑D-09 0 Other NUMBERWUXI-- ExPIRATION DATE <br /> DOMESTIC WELL SAMPLING:0 General MinerallColiforrn Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 DomesticJPrtvate Irrigabon/Agricultural D Industrial 0 Water Quality Monitoring Cl Soil Sampling/Character"flon <br /> 0 Public Water System <br /> If different from OM Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 0 Repiacement Well D Well Alteration/Modification ❑Other <br /> 0 Monitoring Well(s) 0 of wells D Sol Borings) s of bongs 0 Geotechnical s of bongs <br /> 0 Out-Of-Service Well 0 Out-Of-Service Weil Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method g Mud Rota [I Air Rotary ❑Auger ❑!Cable Tool ❑Push Point ❑ Other <br /> Proposed Well`D`epth ft Excavation� in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. In Thickness/Gauge/ASTM Schad 1&0 0 Steel*Iasbc 0 Stainless Steel 11Other <br /> Grout Seal Depth_ it ❑Neat Cement(94 lb bag,/_110 gel water) 0 Sand Cement sack mix/7 gal water <br /> Bentonite 20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fail ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal ODhmenslons:Width It Length It Thick in ❑Christy Box D Stove Pipe <br /> PUMP ❑Submersible Turbine D Other HP Pump Set It Standing Water Level N <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 <br /> YIN$PPEEC. N DLEASE CALL(209)953-7697 <br /> SIGNED TITLE `11 W' �� V DATE <br /> III M1 11 <br /> J <br /> C <br /> r T N <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By -L - Date �) `��'`i Area `r Fr "I Employee IDX � <br /> Grout Inspection By Date oZ 20 ❑ 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 ChscidJ Affrodht Date Permit/ Invoice# Well ID# <br /> Codes Info B h Remitted Servicer testi <br /> EMD 43-06 SM1116 WELL/PUMP PERMIT <br />