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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/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S U 7 - \ .'-l G t C ! 0A C CITYZP- A ca � I '?^U to <br /> CROSS STREET CO��t E(' r/• APN4/�=�_ �/ a <br /> `[ PARCEL SRE-S 6I(, LAND USE APPLICATION#/ p <br /> OWNER NAME {- r\ L-e ,� 1 -�V� `� PHONE SO✓­W V O (.59 I p <br /> w <br /> c'7 ru <br /> OWNER ADDRESS Iti ("-1�f i�L� I ' 11(V( CITY/STATEZyJ P `i (1 `y +� ��l 5/ / <br /> L� <br /> CONTRACTOR \I I '. l��� 1 l Y� `7 PHONE-'j J Cq z/J C,(7( -CX /�-7 7l <br /> J �1 <br /> CONTRACTOR ADDRESS L - )ti�. �(, A CrTY/STATE/LP �.� 4-( c A <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIIZIP <br /> LICENSE 'AC-57 G G-61 L D-09 C Other NUMBER C"C JS EXPIRATION DATE_/ <br /> BILLING PARTY: D OWNER E CONTRACTOR ❑SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)11,Dibromochloropmpane(4392)D Arsenic(4393) ° h" <br /> INTENDED UsE DomesticlPrivate C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Ch8racterization s <br /> D Public Water System d <br /> Ildilfemnl Gam Owner Weler System Name Contact Name w Phone Nur Mer ..T <br /> TYPE OF WORK -,,New Well 0 Replacement Well D Well Alteration/Modification U Other <br /> 0 Monitoring Well(s) #of wells D Soil Boring(s) s of borings p Geotechnical #of badngs <br /> D Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> New Pump 0 Pump Replacement ❑Pump Repair 0 Raise Well Casln <br /> WELL C NSTRUCTION <br /> Drilling Method dud Rotary 0 Air Rotary C Auger D Cable Tool D Push Point C Other <br /> Proposed Well Depth ft Excavation .�,�in diameter -1 Open Bottom '2�,Gravef Pack/Gravel Size )�._in diameter <br /> C Conduct/or'Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter wa in Thickness/Gauge/ASTM Schad L GA' D Steel Plastic 0 Stainless Steel C Other <br /> Grout Said Depth G R 0 Neat Cement(94 lb bag/5-10 gal water) {Sand Cement G sack mix17 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method umped 0 Free Fall 0 Other 0 Retardant I Accelerator(name) <br /> PEDESTAL Installed Hy Driller 0 PUMP Contractor _ 0 Other <br /> Concrete Pedestal❑Dimensions:Width ft Length_eft Thidcin ❑Christy Bax ❑Stove Pipe <br /> PUMP *Submersible[]Turbine 0 Other HP Pump Set i,1 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 /> _I.'yI 43 HCU R ADl O,i'LE .OTT,E RE(?UIRED F0 ail',Sa=CrlCi't3-P. EASE CIAL.L{ C39)5s3-769i 7 <br /> SIGNED r 5s'v�i9�"l��,i(/ZC`a" TITLE V Y r C �rC7�"C-1 r') A— <br /> DATE <br /> cYM�N <br /> Ff <br /> ?3?p <br /> ?� <br /> �s r <br /> gRToNov <br /> I <br /> A MENT U E O LY <br /> Application Accepted By ate Z Area Employee ID# <br /> Grout Inspection By Date ❑ SP�EALW.11 Permit <br /> Pump Inspection By Dale ❑ WAIvER Received r �r <br /> Soil Boring Inspection By Date Constructed Well Depth {,•� ft <br /> COMMENTS <br /> PE SC Received Check#I Amount Date Permit/ <br /> Codes Info Cea Remitted Service Re uest# Invoice# We111D# <br /> �i <I <br /> !a-0e t 11 Rar i d WELL/PUMP PERMIT <br />