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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE <br />- STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE` PERMIT <br />[� WWW.S' OV.Or /ehd <br />JOeADDRESS H <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />c <br />las ild`'em 4n C"/Z",_J/Q� <br />CROSS STREET_a,�C'I� C4 --I r^� S <br />APN O I V ( r �� <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />PHONE 20 2 - Z!o <br />j <br />OWNER ADDRESS 3 /-e44, ue CITY/STATEIZIP V'/j' <br />n� �wl <br />J� ( <br />C <br />CONTRACTOR PIS 1/' ,a � 5(� �-�J(�n S � ✓1 � <br />{-�=--� <br />'217 <br />I <br />PHONE 2 i� ( 9 I -�Z ( Q <br />'CONTRACTOR ADDRESS 1� (� G{ <br />n� <br />CITY/STATE/ZIP_ <br />//�� <br />� <br />1 /)(�(�, L �� <br />SUBCONTRACTOR/CONSULTANT <br />PHONE / �( <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />I <br />j, I n <br />CITY/STATE/CTP <br />'�IJ/—i\- <br />LICENSE &C-57 C-61 D-09 Other NUMBER <br />� <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (43931 <br />INTENDED USEonneK Public i Water <br />Sys 11 <br />Public <br />- industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public VJater System <br />If different from Owner. Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK <br />rvew vveii Replacement Well Well Alteration/Modiricalion Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings <br />PGeolechnical # of borings <br />New Pump <br />Out -Of -Service ice Well Out -Of -Service Well Renewal Cross -Connection Repair <br />r _(Pump Replacement _. Pump Repair <br />Raise Well Casng <br />Drllling Method Mud Rotary Air Rotary _ Auger Cable Tool 'J Push Point Other <br />Proposed Well Depth ft Excavation in diameter - Open Bottom Gravel Pack/Gravel Size <br />Conductor Casingin diameter <br />in diameter / Conductor Casing Depth ft <br />[Grout <br />ell Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Steel _ Plastic - Stainless Steel Other <br />Grout Seal Depth R - Neat Cement (94 lb bag/5-10 gal water) - Sand Cement <br />Bentonite (20 % solids) Other sack mixn gal water <br />Placement Method Pumped free Fall Other <br />_ Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor - Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in Christy Box Stove Pipe <br />PUMP Submersible _ Turbine - Other HP L <br />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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />fAIN144,4j4/1JR(215(G/LNCF NnTIC'F pAnino= <br />2 <br />D <br />0 <br />a <br />N <br />,--T / /DEPARTMENT USE ONLY <br />Application Accepted By _— % L. _ L — Date < AreaEm <br />/ I C n <br />~ � / ployee ID#� <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By 74 <br />Date �) <br />WAIVER RBCBIVed <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth ft <br />WELL /PUMP PERMIT <br />