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WELL/PUMP PERMIT <br />SAN JOAQ GUN ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-342( <br />rvVrv-KEFUNDABL7E PERMIT <br />�/ <br />JOB ADDRESS -1 <br />Z 2A1 <br />CROSS STREET tJ�O jf( <br />OWNER NAME JJ�\ (1 (t( <br />OWNER ADDRESS <br />CONTRACTOR JJ[ a <br />CONTRACTOR ADDRESS <br />CALL (209) 953-7697 FOR <br />I "I ONA__Ul in W <br />ADDRESS <br />57 ❑ C-61 0 D-09 C Other NUMBER <br />1 YEAR FROM DATE ISSUED <br />Cl-zp tINIM/N L(A � w <br />ICEL hSIZE2�LAND USE APPLICATION # <br />PHONE U/D-4090 <br />CITY/STATFJLP I1�aN'^�1 7iz? ]U� <br />PHONE IN- 57-2 I-Iy0 <br />CITY/STATEIZIP���M, (A 19 3`9 <br />PHONE <br />CITYfSTATE2IP <br />ExPIRATION <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (439 1) 0 Dibromochloropropane (4392)11 Arsenic (4393) <br />INTENDED USE ❑ Domestic[Private 'Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring C Soil Sampiing/Characterization <br />3 Public Water System <br />11dieerenl from Ovmen Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br />"Monitoring Well(,) # of wells J Soil Boring(s) 's or borings 0 Geotechnical a of boring' <br />Out -0l -Service Well ❑ Out -Of -Service Well Renewal 17 Cross -Connection Repair <br />Drilling Method gyud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other <br />Ir <br />Proposed Well Depth it Excavation in diameter 0 Open Bottom Gravel Pack/Gravel Sizd in diameter <br />0 Condu r Casing in diameter / Condu or Casing Depth ft 14— <br />Well Casing Diameter In Thidcness/Gauge/ASTM Sched )�_ XSteel ���G///, Plastic 0 Stainless Steel ❑Other <br />Grout Seal Depth ft ❑ Neal Cement (94 lb beg/5-f0 gel water) p,Sand Cement ,� sack mixf7 gal water <br />❑ Benton it (20% solids) G Other <br />Grout Placement Method Pumped 0 Free Fall U Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor'Other <br />❑ Concrete Pedestal ❑Dimenslons: Width ft Length It Thick in C Christy Box J Stove Pipe <br />(PUMP 0 Submersible❑ Turbine ❑ Other HP 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 />MTOr E NOTICE REQUIRED F R I G(P Tj}I'Oj�N�S - PL ASE CALL (209) 953-7697 <br />SIGNED i� HMT TITLE y 1 V �I DATE_ <br />/ EPARTMENTx SE ONLY <br />Application Accepted By �_ L Date �rf Area Employee lD#Z <br />Grout Inspection By �i Date -�� 11 SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Dale Constructed Wellpth fl <br />COMMENTS i., I!^V, C: n2 L.." I i,-� t' itiv ( w .,. .a '; .— /�'A r;> .[I I <br />A <br />0 <br />a <br />N <br />v, <br />mmu <br />M-11 � <br />EMD 43-M WI/1e 12'-l' 72,S-2/ ,lam <br />WELL /PUMP PERMIT <br />