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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMrNTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WVJW.S' V.Or /ehd EXPIR S 1 YEAR =ROm DATE ISSUED <br />JOB ADDRES <br />ll % CITY/Z1 <br />CROSS STI N V / ..1� PARCEL SIZE I L� �l LAND USE APPLICATION # <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS <br />^f ��/� /� �C�ITV/ST\ATEIZJP <br />CONTRACTOR IYYI fmen I f� /,t fvr— 1 A, 1 <br />t <br />CITY/STATE/73P��/ <br />SUBCONTRACTOR/CONSULTANT <br />PHON <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/,, P <br />LICENSE - C-57 C-61 D-09 Other NUMBER U_ <br />EXPIRATION DATE <br />BILLING PARTY: - OWNER . CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:. General Mineral/Coliform Bacteria (439 1) Dibromochloropropane (4392) _Arsenic (4393) <br />INTENDED USE 171 <br />TYPE OF WORK <br />Public Water System <br />evan-111r♦gnculmII S <br />ral Industnal Water Quality Monitoring SDampling/Charactenzatmn <br />If different rrom o—, Water System Name <br />INew well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells L Soil Boring(s) # of bnnngs <br />Geotechnical <br />Out -Of -Service Well ut-Of-Service Well Renewal Cross -Connection Repair <br />New Pump _ Pump Replacementyump Repair kik P <br />pJ Raise Well Casino <br />4 of borings <br />Drilling Method Mud Rotary Air Rotary Auger Cable Too] Push Point y, Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft n diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other sack mixl7 gal water <br />Grout Placement Method - Pumped - Free Fall _ Other _ Retardant / Acra1—t— 1 -- <br />PEDESTAL <br />-- <br />PEDESTAL Installed By - Driller Pump Contractor Other <br />Concrete Pedestal Dimensions Width ft Length ft Thick n Chesty Box Stove Plpe <br />PUMP Submersible _Turbine Other HP Pum Set <br />P It Standing Water Levelft <br />JOAQUI <br />CURREI HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />N 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 LA S. <br />kl;v I OU dCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (203) 953- 69 <br />SIGNED 6/TITLE <br />l DATE <br />Area � / � Employee ID#_�% � f <br />SPECIAL Well Permit 1 <br />WAIVER Received % J 2 7� <br />Constructed Well Depth F_l_y_��,�Q(/pV <br />h'49FNr" <br />WELL IPUfAP PERMIT <br />1.,Z) T411 <br />y�T <br />—1-AKIMtNT USE ONLY <br />Application Accepted By _ <br />`� r'— /�( Date I�D/ <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By <br />Id Date <br />COMMENTS <br />Area � / � Employee ID#_�% � f <br />SPECIAL Well Permit 1 <br />WAIVER Received % J 2 7� <br />Constructed Well Depth F_l_y_��,�Q(/pV <br />h'49FNr" <br />WELL IPUfAP PERMIT <br />1.,Z) T411 <br />y�T <br />