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WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.SIQOV.or4/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS-{�''�12001 S. F14li w&j -1 'VI CITYMP 7�t:CA IS3� 6, <br />CROSS STREET T Zee G4. C��FitY�Ir� APN 204-0 �t��\�PARCEL SIZE /Z•7G LAND USE. APPPLILICA/TIOON# ^7q <br />OWNER NAME y�.i c.fcl v Tf,N,'f/� l g� /J�V(� A 110>5- /1 P�HHOONE--��`�L�-1-t"r,32 - 3-7 1 1 <br />OWN OD SS ^12.oD1 S�•r�I-rry&4+WK,-1 9!9 {� CITY/STATE/ZIP AA04 /v IE7-,A ,(fA- <br />[tic C-/C� C7L ✓,I�C,r��/Tl ^/+�I..c��a.. PHONE <br />ONTRA TOPADDRESS Z017D Coto &bt9 /!�� S017Z LB CITY/STATE/LP-rL))eLOCKt CA- 95-392- <br />L�rsrrRtuT WOU T LOAST- �—XFLzi2ATbr4 PHONE :7-0-9957-7!5V/SUBCONTRACTORICONSULTANT ADDRESS F-0-BC)X 133 CAT` <br />ITYISTATE/ZIP GrrJLDNGii '3r 5500 <br />LICENSE �C-57 D C-61 0 D-09 D Other NUMBER 8 7 I v 1 EXPIRATION DATE) ^31— LOZO <br />BILLING PARTY: ❑ OWNER ONTRACTOR 2S.,JUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacte (4391) :j Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural D Industrial D Water Quality Monitoring XSoil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Comad Name or Phone Number <br />TYPE OF WORK D New Well D Replacement Well C Well Alteration/odi hon D Other <br />0 Monitoring Well(s) # of wells YSoil Boring(s) s of borings XGeotechnicai Z sof borings <br />D Out -Of -Service Well D Out-Of-Serviceell Renewal D Cross -Connection Repair <br />Drilling Method D Mud Rotary0 Air Rotary XAuger D Cable Tool D Push Point D Other <br />r <br />Proposed Well Depth 2q Z it Excavation in diameter ; Open Bottom D Gravel Pack/Gravel Size In diameter <br />D Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter 497 in Thickness/Gauge/ASTM Schad O Steel D Plastic D Stainless Steel C Other <br />Grout Seal Depth!2�0 ft XNeat Cement (94 lb bag/5-10 gal watef) D Sand Cement sack m1x17 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method Pumped O Free Fall D Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By WDriller D Pump Contractor D Other <br />)CConcrete Pedestal ❑Dimensions: Width -A— ft Length --- I— ft Thick in D Christy Box D Stove Pipe <br />PUMP 0 SubmersibleD Turbine D Other HP Pump Set It 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 />MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE � lE�- ING�' �-' DATE -7- 1(- -it WI <br />1� <br />Appllcatlon Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />PARTMENT U)SE O LY <br />Dateqlle,Area mp ee ID# ✓ / <br />Date ❑ SPECIAL Well Permit <br />Date <br />F1 WAIVER Received <br />EH043A6 5/118019 Q / t / / C fe 0 WELL !PUMP PERMIT <br />