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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 r�1 CALL 209 953-7697 FOR INSPECTIONS_ EXPIRES 1 YEAR FRRom DATE ISSUED <br /> W <br /> JOB ADDRESS 1 1 CITY/ZIP _C6f 7':3%( r�li <br /> '{fir! n (1�, (� 1,�tr�t— D <br /> CROSS STREET 1 ' '1 � V R9� PN .011— 1 V V MO PARCEL SIZE M LAND USE <br /> APPLICATION <br /> OWNER NAME +` /nP,HONE `/�{G' I/�////1��" 1 V u! <br /> OWNER AoclSS I 1 CITYISTATE/LP_MA L�6 I %-/u,%/' <br /> CONTRACTOR PHONE r-��, 1 �12 117-9' <br /> CONTRACTOR ADDRESS ' CITY/STATE/ZIP I/I 1 I�/, <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS _ CITYISTATE/ZIP <br /> LICENSE C-57 G C-61 D D-09 _Other NUMBER�!fl�'Zz EXPIRATION DATE •�� <br /> DOMESTIC WELL SAMPLING:[]General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE !DomeslidPnvate NiTigationlAgricultural Industrial r,Water Quality Monitoring L Soil Sampling/Charactenzation <br /> Public Water System <br /> If ddrerenl from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well rWell Alleration/Modification G Other_ <br /> 1 Monitoring Wells) #of wells Soil Boring(s) eof bonrgs 1.Geotechnical tot borings <br /> Out-Of-Service Well 1 Out-Of-Service Well Renewal C Cross-Connection Repair <br /> ' New Pump ❑Pump Replacement -I Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCT10N <br /> Drilling Method h Mud Rot Air Rotary ❑Auger "Cable Tool 0 Push Point G Other <br /> 1r <br /> Proposed Well Depth _tt Excavation in diameter Open Bottom '.I Gravel Pack/Gravel SizeAAV In diameter <br /> C Conductor Casing in diameter / ConduQfo�r Casing Depth It <br /> Well CasingDiameter m Thickness/Gauge/ASTM a/ASTM Sched—�—� R Steel 0 Plastic 1:Stai es*eel 11 Other <br /> Grout Seal Depth 1;;0U Neat Cement(94 Ib bagr5-10 gal water) Sand Cement _sack mix/7 gal water <br /> _Bentonite(20%solids) r,: Other <br /> Grout Placement Method Pumped L Free Fall -,Other I Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller C Pump Contractor 0 Other <br /> Concrete Pedestal CDlmenslons:Width R Length It Thick in 0 Christy Box Stove Pipe <br /> PUMP ':Submersible[]Turbine (I Other HP Pump Set ft Standing Water Level <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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-�P`LoE1�IrA1�SE CALL(209)953-7697 <br /> SIGNED TITLE DfAut I C Y�, t f, DATE10 <br /> F ANT <br /> l AFD <br /> F <br /> DA <br /> /N C <br /> Hii <br /> F gRTo�NTY <br /> MENr <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date / Area Employee ID# <br /> Grout Inspection By to ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring tilspection By a I Constructed Well D/pth It <br /> COMMENTS (1rY✓1� �� iIf'F� F" 7 )f Lry'rilC 1)^�fyil�r f'l�� \Sl�Ac?�LOp��C��(��, <br /> PE SC Received Check#I Amount Da Permit/ Invoice 0 Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 4�69 .1 <br /> I <br /> EHD 13-OB 8/01119 / / Z` (-(-�O /�_ WELL(PUMP PERMIT <br />