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v � ' WEPUMP PERMIT SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468.3420 NON-REFUNDABLE PERMIT www.sigov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS ° I.^� + Cm/ZIPz-;/ G Lt. ::1 U1 y • ' ry ry CROSS STREET 16+ 3 Odi-£"-.:� APN !'- .9 % "' PARCEL SIZE �t LAND USE APPLICATION # A A ae d9 OWNER NAME�+i h3 4'•'Vlt �L !7� PHONE/'�l :.��Cy.'•�C7-<�,�� m OWNER ADDRESS ,J` i' "d` i s w CITY/STATE/71P 4e -1j40!,!!2 AiL ❑ SPECIAL Well Permit CONTRACTOR A v10 l' PHONE (Zi ' !° ,I 5';3 t`1Y4i0, r2- ,,lv CONTRACTOR DORESS �-/Tby C.B..i C°• CITY/STATEMP .3u iy-,&-z c L V'0120 ❑ WAIVER Received SUBCONTRACT RICONS JLTANT P14ONE n By , / c - Date SUBCONTRACTOR/CONS jLTANT ADDRESS CITY/STATE/LP n By ry�9 LICENSE 7 0 C-61 0 D-09 0 Other NUMBER Q l EXPIRATION DATE Constructed Well Depth It BIWNG PARTYI ❑ OWNER ❑ CONTRACTOR ❑ SUBCONTRACTORICONSULTANT IVV go DOMESTIC WELL SAM LING: 0 General Mlneral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) INTENDED U -E )<ba ne3tic/Pdvate ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If dl Terent from Owner: Water System Name Contact Name or Phone Number TYPE OF WORN 0 NevWell ❑ Replacement Well 0 Well Alteration/Modification ❑ Other 0 Mo iltoring Wells) # of wells ❑ Soil Boring(s) # of borings 0 Geotechnical # of borings ecelved Check#! Amount _ _ _ ... 0 Ou -Of-Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair invoice# Well 1D# e Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUC O Drilling Method ❑ Mu I Rotary ❑ Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other Proposed Wel I Dep ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Co ductor Casing in diameter / Conductor Casing Depth ft Well Casing Diam ter _ In Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel 0 Other Grout Seal Dep it 0 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/1 gal water D Be tonite (20% solids) 0 Other Grout Placement Matt od 0 Pumped ❑ FfLre Fall 0 Other ❑ Retardant / Accelerator (name) PEDESTAL Insta ed By 0 Driller ;(Pump Contractor 0 Other ❑ Co crate Pedestal ❑Dimensions: Width_ It Length ft Thi in 0 Christy Box ❑Stove Pipe PUMPj 5u mersible0 Turbine - Cl Other HP Pump Set--12Z)—ft Standing Water Level 2-3 P It 1 HEREBY CERTIFY HAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY RDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND AC E WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERSCOMPEN TION LAWS. MINIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 997 SIGNED - iA-.- TITLE DATE EF At QED 12 ?0?0 U/N 4RT ' ANT y T EHD 43.06 611419 I 6 C� o S 30 WELL !PUMP PERMR DEPARTMENT I]Qr 1"Ihl4 v ApplicatioAccept ad By ��`—� Oa ]� Area Employee ID# /0 6 Grouinspe n By Date ❑ SPECIAL Well Permit t`1Y4i0, ❑ WAIVER Received Pum Inspe n By , / c - Date Soil Bodr) Inspe n By Date Constructed Well Depth It COMMENTS IVV go PE SC ecelved Check#! Amount _ _ _ ... PermiU Date invoice# Well 1D# EHD 43.06 611419 I 6 C� o S 30 WELL !PUMP PERMR