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-t,l ( /zozz- <br />c,� rr&,4 <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468.3420 <br />NUN-KEFUNDABLE PERMIT <br />www.stgov.org/ena <br />CJLPIKCS T YEAR FROM DATE ISSUEL <br />JOB ADDRESS 11372 E:.M&91P05A <br />7—a-CmrizlPST <br />j , <br />Jg52D6 <br />CROSS STREET uL i E t ta. <br />APN 173-04Q40 PARCEL SIZE i.6�ND USE APPIJCATION # <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS &cP) A4L.I7mk-. <br />As CITY/STTATEIZI�P <br />_7=��!y <br />'�Z'y�O�Git <br />CONTRACTOR <br />• •c� <br />CONTRACTOR ADDRESS <br />�-„�PpHHO.1NVE <br />�+. CITY/STATEIZI <br />e�Qa�l[t�Q <br />n <br />SUBCONTRACTOR/CONSULTANT WEST <br />Vim -9, fIyTp <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS 1029 <br />MAlil e- - CITY/STATE21P MwV <br />` 1, <br />V Vi\GiI.L 953 06 <br />LICENSE - C-57 IVC -61 -1 D-09 <br />,XOther & Bit c.z0 NUMBER 4 <br />EXPIRATIONDATE o7'9I -20ZZ <br />�(�•�y Q__ <br />10 2C,2.Z <br />BILLING PARTY: IOWNER <br />I CONTRACTOR X SUBCONTRACTh19C6.N3LLYANT• <br />DOMEsnc WELL SAMPLING: r- General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) F Arsenic (4393) <br />INTENDED USE Domestic/Private J Irrigation/Agricultural _: Industrial J Water Quality Monitoring L Soil Sampling/Characterization <br />Public Water System <br />H different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK - New Well - Replacement Well _ Well Alteration/Modification L Other <br />Monitoring Well(s) 4 o wells _ Soil Boring(s) *of borings J Geotechnical ft of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal I Cross -Connection Repair <br />New Pumo I Pump Reolacement Pumo Repair 7: Raise Well Casinq <br />Drilling Method Mud Rotary I Air Rotary I I Auger I I Cable Tool Push Point I Other <br />Proposed Well Depth ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br />_ Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gouge/ASTM Sched ❑ Steel ❑ Plastic 7 Stainless Steel C Other <br />Grout Seal Depth ft I Neat Cement (94 Ib bag/5-10 gaf water) I I Sand Cement sack mix/7 gai water <br />Bentonite (20% solids) -1 Other <br />Grout Placement Method -1 Pumped - Free Fall -1 Other -1 Retardant / Accelerator (name) <br />PEDESTAL Installed By -1 Driller - Pump Contractor -t Other kt <br />_ Concrete Pedestal LDimensions; Width _2__ ft Length �' _ It Thick I A 4n J Christy Box _ Stave Plpe <br />PUMP - Submersible I Turbine r Other HP Pump Set ft Standing Water Level it <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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DATE <br />DEP RTMENT US ONLY <br />Application Accepted By Date /3 n Area -I 1 Employee ID# _� <br />Grout Inspection ByVV, Date SPECIAL Well Permit <br />Pump Inspection By Date _ WAIVER Received <br />Soil Boring Inspection By Date _ <br />COMMENTS - u° iA A 6j f • 5 S <br />S m P P mL,eA- <br />Constructed Well <br />PE SC R celve Check#/ Amount Date Permit/ Invoice # Well ID# <br />-Cd fk ei -info Casfi Remitted Service west # <br />Z I <br />L�� DA3-0e sr111201 4 &4 . l 3Ss3 3Co�v _._-- <br />WELL /PUMP PERMIT <br />