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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS _EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L-� <br /> N <br /> CITY/zip <br /> CROSS STREET I APIN D <br /> 1I�) ►AA1..\1t 0 �yLI1r�1 PARCEEn�L SIZE ' _LAND USE APPLICATION <br /> S#I OI p <br /> OWNER NAME 1 i� r r 1tV `r 't/ PHONE 1 m <br /> OWNER ADDRESS Z 1V CIA- r--•�rn N <br /> —L_ ! ---- CITYISTATEIZIP"_ <br /> CONTRACTOR L PHONE �] <br /> CONTRACTOR ADDRESS CITY/STATEMP-AD �CLf� q/�"W0 <br /> 0 <br /> SUBCONTRACTOR _ <br /> - PHONE_ <br /> SUBCONTRACTOR ADDRESS CITY/STATE1ZIP <br /> LICENSE 1 C-57 ::--C-61 i I D-09 C1 Other NUMBERV EXPIRATION DATE -2-3 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)_Dibromochloropropane(4392)i,Arsenic(4393) <br /> INTENDED UsE [.'Domestic/Private In igation/Agricultural O Industrial !.Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System__ <br /> It different from Owner Water System Name Conlacl Name or Phone Number <br /> TYPE OF WORK Wew Well 0 Replacement Well D Well Alteration/Modification 0 Other <br /> Monitoring Well(s) _#of wells 0 Soil Boring(s) Mor borings I Geolechniral p of botings <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal -1 Cross-Connection Repair <br /> New Pum Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�Mud oto n Air Rotary D Auger i Cable Tool I Push Point ! Other <br /> Proposed Wall Depthft Excavation It,1 in diameter D Open Bottom LI Gravel Pack/Gravel SizeAt in diameter <br /> -Conduct Casing V in diameter / Conducto as ng Depth_ ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft ':I Neat Cement(94 Ib bag/5-10 gal water) .;Sand Cement _ sack mixl7 gal water <br /> >eentoits(20/,solids) D Other <br /> Grout Placement Method Pumped D Free Fall 11 Other _'Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor '1 Other <br /> -1 Concrete Pedestal LiDimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP _ Submersible_-Turbine C Other HP Pump Set _ ft Standing Water Level_ n l <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 M 4 TR ADV E NOTICE REQUIRED FOR IN �PJEC /ION1AS`'-DP'(Ln�EASE CALL(209 953-I7y{697 <br /> SIGNED TITLE prII�V'r�L�I�f DATE U' V I <br /> RE MFNT <br /> �'/N <br /> vFD <br /> - 110 2421 <br /> 04 <br /> 0 � couRN <br /> HE $::'/V7-' NDP <br /> IleTy <br /> T MFNT <br /> DEPARTMENT USE ONLY <br /> a <br /> Application Accepted By C L �•--' Date rj Area_L Employee ID# <br /> Grout Inspection By Dale-5 �\ SPECIAL Well Permit <br /> Pump inspection By Dale f 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructoq Well Depth tt <br /> C MENTS 5�, r"A I Js l P. � /P?) iY' <br /> f <br /> 101t f l C.c7 0 C.—Li co C V � - <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> EHD43e0 IVOII15 _ -1 WELL/PUMP PERMIT <br />