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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ohd �EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �7 D�l ✓• ,r� �v CITY/ZIP �•��T./_/� 7 ��� /(/' <br /> ALE�yCROSS STREET tr,nr.a�t g f APN153-330-3&0°PARCEL SIZE3 <br /> LAND USE APPLICATIOaN/# <br /> OWNER NAME 4PAO-MOA/D6 PHONE <br /> OWNER ADDRESS 7V9 SCNyLTomle • CITY/STATE/ZIP:r, A" M • <br /> CONTRACTORy,+xepj* SHG PHONE�*lIS73=�(►—"11/ <br /> Ay <br /> CONTRACTOR ADDRESS 7 3f^f GCS CITY/STATE/ZIP SdiVO�/ CA4 qJ a7- <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CIITYISTTATE/ZIP <br /> LICENSE AC-57 ❑C-61 D D-09 ❑Other NUMBER (r�•�7- EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mlneral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)Q Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Imigatlon/Agrlcultural o Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well ❑Replacement Well 0 Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells 0 Soil Bodng(s) #of borings ❑Geotechnical A of bo nge <br /> C Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connectlon Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION D <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other C✓�!C /�-� <br /> Proposed Well Depth_!�?A** it Excavation ;?L In diameter ❑Open Bottom X Gravel Pack/Gravel Slze diameter <br /> I _ ❑Conduc'to'r Casing_� "e <br /> In diameter / Conductor Casing Depth S'� ft <br /> Nit C- Well Casing Diameter!_(_in Thlckness/Gauge/ASTM Schad ,1 SO Steel ❑Plastic ❑Stainless Steel ❑Other 7 <br /> 2,00 P r Grout Seal Depthft 0 Neat Cement(94 Ib bag/5-10 gal water) Sand Cement ��'3 sack mixr7 gal water <br /> -S'ec,-L 0 Bentonite(20%solids) ❑Other <br /> —Grout Placement Method umped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor 0 Other <br /> ❑Concrete Pedestal ODlmenslons:Wdth ft Length ft Thick In ❑Christy Box ❑Stove Pipe <br /> PuMP ❑Submersible Turbine 0 Other HP Pump Set ft 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 /> MI UM 48 H UR ADVANCE NOTICE REQUIRED 1700 §INSPECTIONS-PLEASE CALL(209 9 3- 697 <br /> SIGNED TIXP• �`1D�7 DATE �}l <br /> I010 Y <br /> „ , e <br /> C <br /> I ', Nti9E CNNT, <br /> 1 'T <br /> II <br /> •I i <br /> 1 <br /> DEPARTMENT <br /> rUSE <br /> /JONLY �j <br /> Application Accepted By Date-4 -i- Area �� ( Employee ID# / I <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil,Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chet Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B s Remitted I e uest# <br /> F+liI EV <br /> %tF,Ipt imp ppnyrr <br />