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SAN JOAQUIN COUNTY ENVIRONMENTAL WEALTH DEPART ELAMP PERMIT <br />NON-REFUNDABLE PERMIT 1888 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468J420 <br />Jo <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRAM nik c I... — <br />-d, n <br />e AAIM ri � <br />OGRESS _ <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE <br />)R ADDRESS <br />C-57 Cl C-61 0 D-09 p <br />jjk_ (� Cn„aIP U1t R (,(k Stu. q5�9� <br />APN oI V PARCEL SIZE LAND USE APPLICATION 0 <br />o, <br />PHONE LVq 4 D' i OG� O <br />C/ CITYISTATE2IPt�' t � (� , CA <br />G PHONE A• W --522 ' 1 <br />CITYISTATEQ1P..M , 1 A 5/ C;, <br />PHONE U <br />CITYISTATElL1P <br />NUMBER W 9 y a ExPIRATIoN <br />vOMESTIC VVELL SAMPUNG: 0 General MineraVColiform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE ❑ DomesticJPrivate rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring C Soil Sampling/Characterization <br />0 Public Water System <br />If Aafaent fiom Owner Watt/ System Name Contac) Name a Plwne Cha <br />HYPE OF WORK ew Well 0 Replacement Well 7 Well PJteration/Modification G Other <br />❑ Monitoring Well(s) N of wells ❑ Soil Borings) "'—ng' C Geotechnical +a oonnps <br />❑ Out -Of -Service Well G Out -Of -Service Well Renewal G Cross -Connection Repair <br />WELL CONSTRUCAON <br />Drilling Method ud Rotary ❑ Air Rotary G Auger C Cable Tool C Push Point ❑ Other <br />0 u ,I <br />Proposed Weil Depth�_It Excavation in diameter 0 Open Bottom 0. Gravel Pack/Gravel Size in diameter <br />❑ Conduct r Casing in diameter ! Conductor Casing Depth ` ft <br />Well Casing Diameter in Thickness/GaugelASTM Schad JAJJ— C Steel 0 Plastic L Stainless Steel i I Other <br />Grout Seal Depthj�T It 0 Neal Cement (94 Ib bagFrlO gal water) ❑ Sand Cement sack mixl7 gal water <br />0 Bentonite (20% solids) C Other <br />Grout Placement Metho4 Pumped C Free Fall C Other ❑ Retardant -/ Accelerator (name) <br />PEDESTAL Installed By ❑ Driller C Pump Contractor n Other <br />C Concrete Pedestal GDlmenslons: Width It Length R Thick in E Christy Box C Stove Pipe <br />PUMP ❑ Submersible❑ Turbine 0 Other HP Pump Set ft 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 />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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />REQUIRED FOR INSPECTIONS <br />SPE TIONSP- PLEASE CALL (209) 953-7697 <br />TITLE L r I� r II W NVI DATE m 2�-2 <br />A yMEN <br />El QED <br />?0?1 <br />QUIIy C <br />FNM OUNT <br />EPq R TM&N7- <br />/ DEPARTMENT USE ONLY <br />Appiication Accepted By 1 i DateI Area C Ci, Employee IDN <br />Grout Inspection By S 6i f Date ?C%4 U SPECIAL Weil Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inapedion ey Date Fonstructed Well Depth ft <br />COMMENTS inn J(IY t r 'Nlr ��e VVII r �/it r' %�yC�L�f'/ ����Ju/�1t 1sltly' G lit ' <br />EHD s3t6 BMII16 � � i / 2 ff I X Z WELL IPUMP PERMIT <br />