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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARThWELL/PUMP PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.S OV.O� /ehd <br />c EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET L G - �_ UC <br />i - �.��'� <br />/i PREL SIZE.,,1:PLICATION O OWNER NAME o L/ ' <br />OWNER ADDRESS <br />PHONE /L�•,-i'7.�'--����) y <br />� /i L / i � C�� <br />r�C CITY/STATE/ZIP (//�/✓ .! C �I� <br />CONTRACTOR _���/'j;f/%/�}y/ )(� jA./1--7•�p�� _ t <br />CONTRACTOR ADDRESS PHONE % --f <br />V���'/ f�.� /' -f / <br />Clnl$TATE/ZIP SeT<"c Zi <br />SUBCONTRACTOR/CONSULTANT �� <br />LICENSE �-5] <br />BILLING PARTY: <br />DOMESTIC WELL Sf <br />INTENDED USE <br />TYPE OF WORK <br />PHONE <br />ULTANT ADDRESS <br />Cln!$TA�•TE/7JP <br />-61 D-09 Other NUMBER / } <br />EXPIRATION D/IjTE_ <br />OWNER . CONTRACTOR SUBCONTRACTOR/CONSULTANT / 3 <br />LING. General Mineral/Coliform Bacteria (4391) Dibromochloropropane (43992) _ Arsenic (4393) <br />--- •••y�•�^a�,�D����d� moustnal - Water Quality Monitoring Public Water System y 9 Soil Sampling/Characterization <br />If dittarent from 0- ­ <br />or System Name <br />Contact Name or Phone Number <br />i- oven _.48cement Well Well Alteration/Modification Other <br />Monitoring V., # of wells Soil Bonng(s) » of borings <br />Geolechnical » of borings <br />Out -Of -Service WWII Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump \ Pump Replacement - Pump Repair <br />rt- _ Raise Well r:aalnD <br />Drilling Method Mud Rotary Air Rotary . Auger Cable Tool _Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth fl in diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Grout Seal Depth Steel Plastic Stainless Steel Other <br />p R - Neat Cement (94 Ib bag/5-10 gal water) - Sand Cement <br />Bentonite (20% solids) Other sack mixt) gal water <br />Grout Placement Method Pumped Free Fall Other <br />- Retardant f Accelerator (name) <br />PEDESTAL Installed By Driller - Pump Contractor Other <br />Concrete Pedestal _ Dimensions: Width ft Length It Thick <br />in _- Christy Box Stove Pipe <br />PUMP Submersible _ Turbine _ Other HP <br />Pump Set <br />It Standing Water Level -yr <br />I HEREBY CER IFY 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 LAW <br />MINI !rjU R .NOTIG REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953- 697SIGNED ���/�' "Jr"1)%/J/ j /�t <br />/� TITLE �4`�"" /�� ` /'9 <br />.....,,.... ^—p— Dy - ice-- Date 4—//vZa( Area Employee ID# <br />Grout Inspection By DA <br />Date / <br />SPECIAL Well Permit <br />Pump Inspection By Date <br />�T�T��`���� WAIVER RBCBIVed <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS ft <br />WELL /PWAP PERMIT <br />