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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR WELL/PUMP PERMIT <br />ENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />WWW-Sigov.orgirehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS (o1IA� A r A 0 %� _ <br />CROSS STREET CITY2IP �,uN <br />^ _ m <br />T�^ APN� -J' V PARCEL SIZE /' S LAND USE APPLICATION * D <br />OWNER NAME t a✓� o <br />ti o <br />.7 m <br />n 9'CX_. <br />PHONE f-.— - y . "zip s <br />OWNER ADDRESS � �(J �,� �` <br />j CITYISTATE/ZIP_ti_�C,k�n Cd— SZ1� <br />CONTRACTOR &QQY NALL1a a, JA)Ct A f 1 "C <br />'�-.�1 • PHONE�a-R'3 (� 21� <br />CONTRACTOR ADDRESS _ 12. Q (,L i I r Q X Q ii t� <br />Lei CITY/STATE/LP i jLNC.i <br />SUBCONTRACTORICONSULTANT <br />IV I PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE %--C-57 C-61 t_ D-09 J Other 6 I <br />NUMBER EXPIRATION DATE 2 <br />BILLING PARTY; �. OWNER <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING; General Mineral/Coliform Bacteria (4391)_ Dibromochloropropane (4392) _Arsenic --- <br />(4393) <br />INTENDED USE iS Domesticiprivate _ Irrigation/Agricultural - Industrial - Water Quality Monitoring - Soil Sampling/Characterization <br />_ Public Water System <br />If different from Omer. Water System Name <br />TYPE OF WORK-- New Well Contact Name or Phone Number <br />Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) « of wells Soil Boring(s) � or borings <br />Out -Of -Service Well Geolechnical 4 of bonngs <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />J New Pump XPum2Replacement Pum Repair <br />WELL CO_ NSTR__ UC ON=Raise Well Casin <br />Drilling Method _ Mud Rotary .. Air Rotary _ Auger Cable Tool _ Push Point <br />Proposed Well Depth ft - Other <br />Excavation in diameter = Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth fl in diameter <br />Well Casing Diameter_ in Conductor <br />Sched <br />Grout Seal Depth fl Steel _ Plastic Stainless Steel Other <br />Neal Cement (94 Ib bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) __ Other sack -,.R gal vraler <br />Grout Placement Method - Pumped Free Fall Other <br />- Retardant/Accelerator (name) <br />PEDESTAL Installed By Driller - Pump Contractor Other <br />Concrete Pedestal _Dimensions: Width ft I a„r,m <br />X Submersible J Turbine Other HP 2r= <br />Pump Set it Standing Water Level (I <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 LA <br />hi1N � <br />OU . NCE NOTICE REQUIRED FOR I_NSP <br />SIGNED- / (� �C�TJiONS -PLEASE CALL (203' <br />7sg; <br />Z <br />" L ! ��/���L__ TITLE �7��%/�� DATE ✓ j� <br />J <br />PAYMENT <br />RECEIVED <br />AUG 0 3 2029 <br />N JOAQUIN COUNTY <br />ENVIRONMENTAL <br />A! TH DEPA'.?TMENT <br />DEPARTMENT USE ONLY <br />Application Accepted ByT—_ q jr <br />Date CP s .� Area ef �% Employee ID;r )A <br />Grout Inspection By Dale <br />Li SPECIAL Well Permit <br />Pump Inspection By Date i > - <br />WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth It <br />WELL rPU?. P FERMI <br />