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ti <br /> z <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS MAMA PA CrtY/ZIP 2 <br /> nr <br /> VN3 �0CR099 STREET -p2n <br /> PARCEL SIZE LAND USE APPLICATION# <br /> OWER NAME Ms LV tN `YQY& tiNPHONE U 11o <br /> N <br /> II r(I��//�� ��/)� (' A2.016-1 <br /> j to <br /> OWNER ADDRESS is tp / W M ISSN"o N T 1/' CITY/STATFJLP qq, 'GA A2.0 6 <br /> CONTRACTOR Y ,��P�HONE_ 2,01 X922 'Ir"1 1b <br /> CONTRACTOR ADDRESS I CITY/STATEMP_M 0��1 jb <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP <br /> LICENSEC-57 0 C-61 0 D-09 ❑Other NUMBER ��ZZ EmRATION DATE • / O <br /> DOMESTIC WELL SAMPLING:O General Mineral/Coliform Bacteria(4391)O Dibromochlompropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Dome9ticJPrivate Irrigalion/Agricullural ❑Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water System <br /> If dtllerent horn Owner: Water Syst—Name Contact Narne"Phone Number <br /> TYPE OF WORKOw Well ❑Replacement Well Cl Well AlteralbnlModilication 0 Other <br /> ❑monitoring Well(s) #of wells D Soil Borings) a o1 bO kV' ❑Geotechnical a d borin' <br /> ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump 0 Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ud Roar 0 Air Rotary 0 Auger pCableTool 0 Push Point 0 Other <br /> Proposed Well Depth ODD It Excava0on in diameter 0 Open Bottom 0 Gravel Pack/Gravel Sizc*Q_in diameter <br /> ❑Conductor Casing in diameter r CondL or Casing Depth ft <br /> Well Casing Diamater.0 In Thickness/Gauge/ASTM Schad a � leel D Plastic D Stemless S el ❑Other <br /> Grout Seat Depth OU It ❑Neat Cement(94 lb bag/Fr10 gal water) Sand Cement sack mix/7 gat water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method XPumped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal ODimensions:Width ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible Turbine D Other HP Pump Set It 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MUM HID V NCE NOTICE REQUIRED FOR INSPEC IONS,I-PLEASE CALL(209)95�3J-7697 �J <br /> SIGNED TITLE Y 1 ,V DATE !11 -Ivu <br /> YI <br /> I/V/ <br /> 24206N N �NTY <br /> T MFNT <br /> DEPARTMENT USE NLY /� /� <br /> Application Accepted By GXZLL' Date /U d7 Area N '7 Employee ID# Dr'1 <br /> Grout Inspection By Date cl� [ 1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constru edd Well Depth ft <br /> COMMENTS 1YX <br /> PE Sc Received Check#/ Amount Date PermIV Invoice# Well IDS <br /> Codes Info B Cash Remitted ServiCO R Uast*. <br /> v �a_ o L1 ) 05Ut <br /> N <br /> EHO 11-09 8N1//e � � �� WELL RUMP PERMn <br />