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�tIQ-rnl n(�ON �a�Gl� Ilc• �� --- <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELToN AVENUE - STOCKTON CA 95205 - 12091 /ae U2n <br />FROM DATE <br />JOB ADDREss <br />CITY21P ,�i�1 A <br />CROSS STREET in <br />/� % <br />a <br />�z <br />Iny.-f'TVO r <br />Ap <br />PARCEL SIZE21Q-LAND USE APPLLIICATION`# <br />OWNER NAME <br />r <br />Far/a, GI / <br />r <br />PHONE <br />D2L5/ <br />OWNER ADDRESS <br />l1I <br />r <br />/fr -fj <br />CTY/STAT,.P rl 1'f C✓q <br />CONTRACTOR <br />G <br />PHCINEE p�n--1(/✓/�- <br />2e <br />CONTRACTOR <br />CONTRACTOR ADs <br />I S <br />J/} q5-)97 <br />CTfr7STATERJP� <br />SUBCONTRACTOR <br />PHONE <br />ADDRESS <br />C-57 ❑ C$1 ❑ D-09 ❑ Other NUMBER WWa VL+A-- ExPIRATWN <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ DomesticlPrivate Irzigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK Mew Well 0 Replacement Well 0 Well Alteration/Modificalion ❑ Other <br />C Monitoring Well(s) # of wells D Soil Boring(s) a of borings 0 Geotechnical • of b—it. <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method �MudRotary C Air Rotary n Auger 7 Cable Tool ❑ Push Point ❑ Other SAN <br />Proposed Well Depth 00I ft Excavation 1i -j, in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size* in <br />0 Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter in Thicknesa/Gauge/ASTM Sched ) L• Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth © R n Neal Cement (94 Ib bag15.10 gal water) Sand Cement t� • �1 sack mix(7 gal water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method Pumped 0 Free Fall 0 Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor D Other <br />D Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in 0 Christy Box D Stove Pipe <br />Eu _MP 0 Submersible Turbine 0 Other HP Pump Set it Standing Water Level it <br />1 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 />MI 48 HOUR ADV[ C�jjl E NOTICE REQUIRED FOR., SE Cr--Tk1ONS - PLEASE CALL (209 953-7697 1 <br />SIGNED � •/`r '— TITLE '— \ 1 NNW DATE <br />to <br />D <br />0 <br />(fin <br />m <br />PA <br />iEFC M' rtrT <br />LSI V EJ) <br />08 1011 <br />IAQUjN CO <br />IJNTY <br />DPARTM NT <br />DEPARTMENT USE ONLY <br />Application Accepted By ' <br />r'� Date V?' ! Area ! ( Employee ID# <br />Grout Inspection By Date 0.� l'l ill ❑ SPECIAL well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Sofl Boring Inspection By Date Constructed "ll Depth ft <br />COMMENTS ;�_� } �('�� r iS r't', T <br />EHD 41-06 &011196 _ /� / / / � WELL (PUMP PERMIT <br />7 <br />