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kJAW 64'0 <br />- pjifo <br />WELLIPUMP PERMIT <br />:'.JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />www.;,jgov,oreg!end <br />EXPIRES "I YEAR FROM DATE ISSUED <br />JOr: ADDRESS CITY/ZIP% <br />CROSS STREE=T (/ <br />—.,/9 � � _ __APN-V� I <br />� �ARC.ELSI7_E-2,62 LAND USE. APPLICATION dl <br />OWNER NAME G/C. A —ba <br />/�/� lJfr� .-- — - /PHONE _ 2 .F -3 <br />OWNER ADDRIESS �-/ r 4-2 % CITY/STATE/ZIP 6,-t C <br />CONTRACTOR — /GJ __. %i /�,-1 —__ PHONE_, ,- A1/,) <br />CONTRACTOR ADDRESS --__ _ --_— CITY/STATE/ZIP- L(/c'JO� • 0- — — <br />SUnCONTRACTOR/CONSULi'ANT-vel _-----__^__— <br />SUt3C0NTRA{.T0R/CONSULTANT ADDRESS CITY/STATE/ZIP <br />PHONE <br />LICENSE 1.1 C-57 i I C-611 I I D-09 fl Other- NUMBER 3 1- .1 _ ExPIRATION DATE—. -6-_S <br />BILLING PARTY: 'OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL 3-AA4PLING: ' Gene,ral l0ineral/Coliform Bacteria (430'1) , Dibronlo(.hloropropane (4392) Arsenic (4393) M <br />INTI`NDED USE I I Domestic./Private Irrigation/Agricuttt.Iral 1-I Industrial II Water QUalily Monitoring t1 Soil Sampling/Characterization k�� <br />I I Public: Water System-----__-_-_ _ _ - ___-- —_ <br />Ir (lifferPnt (rein Owner: Waler System Name Conlad Name or Mime Number <br />I YPE OF WORT( )( New Well I:1 Replacement Well t 1 Well Alteration/Modification I I Other <br />I_I Monitoring Wells) # of wells n Soil QornTel(s) -- tear borings <br />110LIt-OF-Service Well ❑ Out -Of -Service Well Renewal <br />Wlew Ptlmp-_n Pump Replacernenl U PumI.> Re:prrir_-_----- <br />WEt.I_ CONSTRUCTION <br />Drilling Mothod Mud ROtMY i I Air Rotary II Auger 17 Cable Tool 11 Push Point <br />0 Geotechnical fe of borings <br />I I Cross -Connection Repair <br />V1 Raise Well Casino <br />I Other <br />Proposed Well Depth -SC'V fl Excavalion .L—. in diameter I l Open Bottom 1 I Gravel Pacl</Gravel Size in diameter <br />Conductor Casing—._•- in diameter- / Conductor Casing Depth <br />Well Casing Diameter In -n ICI<ness/Gauye/ASTM Scheel �aP _ H Steel <br />Grout. Seal Depth Et ft I -t Neat Cement (94 lb hagl5- ll) gal wafei) <br />i t Bentonite (20%, Solids) r Other <br />Grout Placement Method 1 I Pumped I-1 Free Fall I.I Other _ tJ Retardant / Accelerator (name) — <br />PEDESTAL Installed By ADdller Fi PUrnp Contract0rl Other <br />_n Concrete Pedestal IlDifnrnslons: Width _ ft Length L fl Thick in 0 Christy Box IJ Stove Pipe <br />PUMP - Submersible 1-i Turbine I HP Pump Set— ft Standing Water Level- it <br />>,Plastic ❑ Stainless Steel ❑ Other <br />ASand Cement mix/7 gal water <br />I HEREBY CERTIFY THAI- 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 130AIRD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION I_AtIVS. <br />MINIMUM 48 HOU�ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />7 <br />SIGNED 1 --� -------- ---- TIl'I E�./�1�" ------------ DATE <br />-!l— <br />rn <br />m <br />D <br />0 <br />0 <br />m <br />m <br />EI ARTMF_NT USE 0 ILY <br />Applicgtion Accepted_ -- Elate: ��� Aea_C��— Employee ID#� <br />Grout Inspection 13v -.----_ —_-__.-- Datr:.-----_-- SPECIAL Well P01 -I -r if <br />Purnp Inspection By _._ Date -- -- WAIVER Received <br />Soil Boring Inspeclion By --.------_---- Date _ — Constructed Well Depth _ ft <br />coMlvtrNTScj►_ ro S cul+- _S oh b�y1LC'y�Gr on �Qrm,�, �erY►+,� ex YtG�EG%-jam o aV/Q) Cg <br />r ri <br />!_� Sr <br />_ <br />Recchred <br />=sy <br />Check <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # Well IDI! <br />ICA <br />(7111U2.019 WELL/PUMP PERMIT <br />