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WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY EWROWAENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT / SjgGV,O ! <br />I� _ F,XPIRES 1 YEAR FROM ❑ATF Icm tvn <br />JOB ADDRESS I" <br />CROSS STREET ci2cy eC(. O <br />APN � <br />CtTY♦-dP777 <br />�D / ppRCQ <br />SIZE ( w � LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CITY/STATEMP <br />CONTrtACTOR <br />PHONE����/ J <br />CONTRACTOR ADORES <br />,n �C <br />GTYISTATE/Z P � J <br />SUBCONTRACTOR/CONSULTANi '� <br />— <br />PHONE <br />SUBCONTRACT /CONSULTANT ADDRESS <br />LICENSE ,57 ❑ C-61 C D-09 U OtherNU1tBER�tM <br />E7xPiRATION DATE <br />BILLING PARTY: ^_ OWNER C CONTRACTOR 7 SUBCONTRACTOR/CONBuLTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) = Dibromochloropropane <br />S <br />-Lmm tDL 0mesIIC1PrivaIe a ca <br />Irrigation/Agnrltural ., Industrial <br />(4392) tl Arsenic (4393) <br />r, WaterOua ttyMo ttoring <br />Public Water System <br />G ShcSampfrng/Characterization <br />It dnfarent from Owner. Water8ystem NW <br />Comae Name w Ph.. Number <br />TVPE OF WORK New Weil 7 Replacement Well = Weti Alteration/Modific aliOn -: Other <br />Monitoring Well(s) # of wells (I Soil Borings) <br />-' Out- <br />D 0f b ings ❑ Oeotechniral p or borings <br />ice O0 � Out -Of -Service <br />Pump <br />New pump _-j Pump ReDlacement - P.._,, o...-:. <br />Well Renewal Cross-ConnecUon Repair <br />Drilling Method Mud Rotary E Air Rotary Auger 7 Cable Tool �I Push Paint : Other <br />Proposed Well Depth fl Excavation in diameter _ Open Bottom a Gravel PadUGrevel Size <br />Conductor Casingin diameter <br />in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thidtness/Gauge/ASTM Schad C Steel D Plastic C Stainless Steel Other <br />Grout Seal Depth it = Neal Cement (94 Ib bag/5-10 gal water) 'I Sand Cement <br />Bentonite (20% solids) :;Other Saar mix17 gal water <br />Grout Placement Method C� Pumped = Free Fall _ OtherL Retardant / Axxeteratnr rnam.i <br />Installed By - Driller _ Pump Contractor - Other <br />7 Concrete Pedestal GDlmensions: Width ft Lend <br />in 7 Christy Box Stove ploe <br />submersible^ Turbine =Other HP Pump Set <br />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 />WORKEf�6 COMPENSATION LAjNS,—� <br />CELL (209) 9 ' -7 7A <br />DATE <br />D <br />S <br />A <br />W <br />PA <br />JV! <br />leop; <br />'iQ(1//v <br />?o pARTM7b <br />r <br />Application Accepted BBaleE AreaZZZ Employee ID# / JQ <br />Grout Inspection By Date SPECIAL Well Permit / <br />Pump Inspection By �-ti- f / Dale t 2� J WAIVER Received <br />Soil Boring Inspection By <br />Dale <br />COMMENTS Constructed Well Depth ft <br />1 4 j2.1 'it t v, gi {� g (> 1 L�y 7 t X15 <br />WELL P. umP PERMr <br />