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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6231(209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd /,EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADOREss (25 203 Ct hC t a e- Crrra. AC-C_ (T1 9 5 aU m <br /> CROSS STREET C d[1 t e r`` t '7. APNad-A -09_PARCEL S nP?a LANA WE AApp�ucmw i 0 /'S�j <br /> OWNER NAME { /C`1_S`^ �/"l t /fes /J7 pPIIOhE(JCN5_-i tG/30-6 -I' <br /> OWNER ADDRESS 1��r+ / ` r�/1�k 1 I 1 V vl CnYISTATE/LP `(K -I rC V C! ^ �� G <br /> CONTRACTOR �G I��/-`,? `�j I I` 1'n C1 ft. a4^.3w,9-a77q <br /> CONTRACTOR ADDREss ,�'U �,G X 4 a CITY/STATE/MP C� �I7 CA <br /> A 9 C,5 2 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUSCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE .0-57 D G61 L D-09 D Other NUMBER.... f 3 93 ERPIRATIONDATE 7-31 1 -22 <br /> BILLING PARTY: D OWNER D CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:-General MineraLlColiform Bacteria(4391) Dibromochloropropane(4392)o Arsenic(4393) <br /> INTENDED USE DOmeStic/Prlvate .!Inigation/Agricultural n Industrial Water Quality Monitoring ^Soil Sampling/Characterization <br /> Public Water System <br /> If diRerent t—Owner: Water System Name Cantad Name or Phone Number <br /> TYPE OF WORK ,New Well r Replacement Well D Well Afteration/Modificstion D Other <br /> .Monitoring Well(s) #of wells ❑Soil Bonng(s) #at bednas D Geotechnical s or hodngs <br /> Out-Of-Service Well O Out Of�Service Well Renewal ,Cross-Connection Repair <br /> New Pump D Pump Replacement D Pump Repair E Rake Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method /,Mud Rotary G Air Rotary i. Auger D Cable Tool i Push Point D Other <br /> Proposed Well Depth 4 5 ft Excavation 1:2—in diameter Open Bottom ),t,Cxavel Pack/Gravel Size )_ _in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched �'� �' Steel Y Plastic L.Stainless Steel I Other <br /> Grout Seel Depth fl Neat Cement(94 lb 6ag/5-10 gal wafer 5(Sand Cement 1 C. sack mix/7 gal water <br /> i!Bentonite(20%solids) L Other <br /> Grout Placement Method "umped J Free Fall 5 Other _i Retardant I Accelerator(name) <br /> lEglILLTAj. Installed By '',-.Driller Pump Contractor Other <br /> Concrete Pedestal:1 Dimensions:Width F, ft Length ft Thick in -Christy Box Stove Pipe <br /> PUMP ;r:,Submersible.- Turbine 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(21)9)953-76997) <br /> SIGNED TITLE �I f Nr� ICAC T DATE P <br /> I <br /> I . <br /> q <br /> I <br /> �' SFO <br /> 23 20 <br /> :( n /N <br /> r ^MA I <br /> M�T �NTy <br /> 1 <br /> AytMENT U E O LY <br /> Application Accepted By ate Z AreaAS&EAL Employee ID# p� <br /> Grout Inspection By Date ell Permit <br /> Pump Inspection By, /' Zi g Date L] WAIVER Received/ <br /> Soil Boring inspection By Date Constructed Well Depth4� ft <br /> COMMENTS <br /> 10-06 <br /> SC Received Checkl4 Amount Da Permit/ Invoice# Well ID# <br /> To Ca Remitted Service Re uest# <br /> J <br /> VJWA.2-f 2_33v: <br /> 6111/2010 '� ' WELL/PUMP HERMIT <br /> ��' �/28g�g332- <br />