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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />1NUIV-KEFUNDABLE PERMIT 1l GALL ZU "3-/ 9/ FOR INSPECTIONS cAMIKl T T AR FROM UAIE I55UE0 <br />JOB ADDRESS IJP: V•`U(r� �1ITf r� 'IV? VWi �y`'L- i �--� CITY/ZIV' <br />CROSS STREET -AJ C�',:J - LC 'N= f1 PN - PARCEL $IIE'(I <br />W - LAND"PUCATION # <br />OWNER NAME HONE It U JC��.(' <br />OWNER ADDRESS YrtV66wllll &6(V CI (STATE/ZJP/," PII)'VV(11 <br />CIS�l <br />G <br />^ �- <br />CONTRACTOR PHONE2-v 61 <br />CONTRACTOR ADDRESS /) FkAt(C Il'llV <br />CITY/STATE/ZJP (kt)r'.i <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEIZJP <br />LICENSE -57 C-61 D-09 Other NUMBERiZOyV_A <br />E%PIRATIONDATE <br />DOMESTIC WELL SAMPUNo: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ySoil Sampling'Characterization <br />Public WaterSystem <br />It dif—m hom Owner Water System Name C.11 -t N-1-11 PI N—d— <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) a ul bo,mgs SOGeotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pumo Pumo Reolacement Pumo Reoair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary i Auger Cable Tool Push Point Other <br />Proposed WeR Depth i Y -� ft Excavation ��_ in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />iii '(p 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 iS-10 ftJ7�Neat Cement (94 Ib bags 10 gai water) Sand Cement sack mw7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method $ Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions. Width _ ft Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set It Standing Water Level It <br />I HtREBY 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 />MIN17411UM 2q'�iQ 1R ADVANCE NOTICE REQUIRED FOR IINSPECTIQNS - PLEASE CALL (209) 9p3-7997 <br />SIGNED V/U'� TITLE +'N�'�i.) �l t[ f _i ✓�� t Sr_ DATE�31 zf <br />Grout Inspection By Date orcur4v vvc.. rcnnu <br />Pump Inspection By ' Date WAIVER Received <br />Soil Boring Infection By. Date_ rj Constructed Wgl Depth ft <br />PE SC Rec ived Check#I Amount Permit/Codes Info B Cash emitted Date Service Re uest # Invoice # Well ID# <br />EHD 43-05 8,01,16 WELL (PUMP PERMIT <br />1 <br />