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0 (A !I g <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232 (209) 468.1420 <br />WWW.S OV.OT /ehd EXPIRES 7 YEAR FROM DATE ISSUED <br />NON-REFUNDABLE PPERMIIT/ <br />1�•u ` - <br />JOB ADDRESS q 1N 'mac T1`tII " <br />CrTYRIP � t 5 iC4' <br />�I�✓"i" <br />CROSS STREET ftll1 �J�� /�[e^� <br />APN M"0 <br />�{ <br />`0 PARCEL SIZE" & LAND USE APPLICATION # <br />/ �� <br />OWNER NAME L.lp!� 5 "q r.-riln l comp('ry <br />PHONE <br />OWNER ADDRESS ploP Trirvi!� PkY4ao <br />CITY/STATE(LR SfO( k 1 Jn I <br />j5� G <br />tT <br />CONTRACTOR <br />t <br />PHONE 2m\26,1^ V70 <br />CONTRACTOR ADDRESS 102 s110111-kf1w, VAY <br />Cm'/STATE/ZIPLoaf CA- 15';HO <br />SUBCONTRACTORICONSULTANT 6f1AJ <br />PHONE Sst4e <br />C A r <br />SUBCONrRACTOR/CONSULTANT ADDRESS SA 1 Y `G <br />IP C. �`- `v <br />LICENSE )LC -57 C-61 i'. D-09 Other <br />NUMBER W On1 FxPIRATION DATE -!�'r�{ <br />WON 1` ` 20VS <br />BILLING PARTY: ,OWNER CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: __ General Mineral/Coliform Bacteria (4391) ..1 Dibromochloropropane (4392) _.: Arsenic (4393) <br />INTENDED USE Domestic/Private - Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If driferent from Ovmer: Water System Name Contact Name or Phme Number <br />TYPE OF WORK New Well Replacement Well Ll Well Alteration/Modification Other <br />Monitoring Well(s) #of wells 0Soil Boring(s) NOt bO""gs x, Geotechnical Not bongs <br />Out -Of -Service Well U Out -Of -Service Well Renewal Cross -Connection Repair <br />New PUMD PUITID ReDlacement D PUMD Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary A Auger p Cable Tool Push Point Other <br />Proposed Well Depth 5� �0 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth I S - �20 R � Neat Cement (94 lb bag/5-10 gal water) - Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Othel <br />Grout Placement Method Pumped Free Fall - Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions . Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine - Other HP Pump Set ft Standing Water Level h <br />1 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 />(/MDI�N,IITL <br />MU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-77697 <br />SIGNED 'Z'I[. TE 5"Mik G e010*4% S" DATE 11-`10-2` <br />DEPARTMENT USE ONLY {� <br />Application Accepted By Date I I 1 d / Area L—), I Employee ID# / �I <br />Grout Inspection By Date _. SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soll Boring Inspection By <br />COMMENTS - 1-rchAle <br />Constructed Well Depth <br />PE <br />Codes <br />SC Received Chet:J;WAmount <br />Info h <br />Date Pertnttl Invoice A Well IDA <br />Remitted Se Ica Re uest A <br />37r� <br />� o <br />113It <br />EHD43U6 6/118019 WELL/PUMP PERMIT <br />