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L WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 NUN-KEFUNDABLE PERMIT www.slgov.orq/ena tAYIKt, 'I TCAK I -RUM UAIL lbbULU JOB ADDRESS CITY/ZIP�� CROSS STREET APN PARCEL SIZE LAND USE APPLICATION �l OWNER NAME—/ PHONE ,� OWNER ADDRESS I1 Al \ `^` �V-'/N "A n C' -4e CITY/STATE/ZIP�T G '% 1�/ CONTRACTORK n/,� ail A V PHONE CONTRACTOR ADDRESS / _ CITY/STATE2IP SUBCONTRACTOR/CONSULTANT %j��.,,�; p� PHONE SUBCONTRACTOR/CONSULTANT ADDRESS \ Q�� i� 1gYC� C�IJT%Y/jST�A}TE21P 7% LICENSE \X-57 - C-61 [i D-09 ❑�Other �CNUMBER _f /d qj' )\ r IF EXPIRATION DATE 014 BILLING PARTY: '� OWNER U eoNTRACTOR C SUBCONTRACT."FUC�ONSUL-TA`,AT DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) :1 Arsenic (4393) INTENDED USE ❑ Domestic/Private C Irrigation/Agricultural C Industrial C Water Quality Monitoring ;X. il Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well D Well Alteration/Modification C Other ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #ofbodngs V116e.technical #of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pumo ❑ Pumo Reolacement 7 Pump Repair C Raise Well Casing Drilling Method ❑ Mud Rotary C Air Rotary - Auger ❑ Cable Tool C Push Point E Other Proposed Well DepthF it Excavation in diameter J Open Bottom ❑ Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad J Steel J Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth It KNeat Cement (94 lb bag/5-10 gal water) -1 Sand Cement sack mix/7 gal - Bentonite (20% solids) C Other Grout Placement Method efumped C Free Fall D Other C Retardant I Accelerator (name) PEDESTAL Installed By F] Driller ❑ Pump Contractor 7 Other Concrete Pedestal UDImensions: Width It Length ft Thick in L Christy Box _ Stove Pipe PUMP Submersible i Turbine I Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. jz�j . T 312 !S DEPARTMENT USE ONLY Application Accepted By Date Area Employee ID# Grout Inspection By Date J SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Baring Ins ctlon By / D to Constructed Well epth AMPNTS i L /LO . MJi. r n /JfL�. t Dc_ iG n'x -�- i �✓ 1 .,-,K ft IX LTH i