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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 />JOB ADDRESS L J` �YS O <br />CROSSSTREET �r/A`PN O <br />OWNERNAME/rN IJ&1104 <br />1 YEAR FROM UATE ISSUED <br />CITY/ZIP '.- <br />SIZE LAND USE APPLICATION # <br />PHONE 2--e `'� <br />OWNER ADDRESS /j�j�V3 p J�// CITYISTATE/ZIP <br />CONTRACTOR _'d'EXj G&,of, `�S ©a/r.-«� _ PHONE-,+%�L��J}�Y, •��Iy F �^� ' <br />CONTRACTOR ADDRESS CITY/STATE/ZIP✓`T/!�J /�dY �� <br />SUBCONTRACTOR/CONSULTANT PHONE 3 ✓� ' +; L 2� <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE 04,-57 0 C-61 II D-09 �U/Other NUMBER 27gr EXPIRATION DATE <br />BILLING PARTY: •, OWNER V!V.ONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: i 1 General Mineral(Coliform Bacteria (4391) ! Dibromochloropropane (4392) . Arsenic (4393) <br />INTENDED USE omestic/Private n Irrigation/Agricultural D Industrial n Water Quality Monitoring D Soil Sampling/Characterization <br />CI Public Water System <br />If different from Owner: Water System Name Contaol Name or Phone Number <br />TYPE OF WORK }IL New Well 11 RPDIBCernent WPII IT Well Alterafinn/Mndifirntion rl Olher <br />n Monitoring Wells) # of wells a Soil Boring(s) 9 of borings O Geotechnical At or borings <br />0 Out -Of -Service Well n Out -Of -Service Well Renewal fi Cross -Connection Repair <br />SJfew PUmD D Pumo Replacement D Pump Repair D Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method 5&ud Rotary Il Air Rotary D Auger 0 Cable Tool D Push Point D Other Jf <br />Proposed Well Depth 7kj0 ft Excavation —I)— in diameter 0 Open Bottom 46ravel Pack/Gravel Size 3 in diameter <br />D Conductor asing in diameter / Conductor Casing Depth it <br />Well Casing Diamete in Thickness/Gauge/ASTM Schad ,7Zi D Steel i<Piastic D Stainless Steel 0 Other <br />Grout Seal Depth it n Neat Cement (94 /b bag1540 gal water) Sand Cement 10.-2 sack mixR gal water <br />D Bentonite (20% solids) D Other <br />Grout Placement Method 04umped 0 Free Fall Ci Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By riller 0 Pump Contractor 0 Other <br />❑ Concrete Pbdestal ODimensions: Width it Length it Thick A in D Christ, Box D Stove Pipe <br />PUMP o<_I Submersible Turbine D Other HP Pump Set it Standing Water Level it <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. 1 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 />MINIMSJM j8 HOyR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DE A�TMENT USE ONLY <br />Application Accepted By � Date o r3 2' Area Employee ID# l �l <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Dale _ WAIVER Received <br />Soil BoringI e,,c,/y'on By Date CO <br />ted Well Depth <br />COMMENTS �(i fIL�P !aS 'I Ian USA �� <br />O <br />m <br />N <br />EHD43-06 61111201P t t WELL /PUMP PERMIT <br />0 <br />�yy NIMMEMONERVA <br />NIINAMMS7rME <br />CSF <br />/i�'/�� _ _ �•i'���►��.��d111,� • • �Q�]� <br />EHD43-06 61111201P t t WELL /PUMP PERMIT <br />0 <br />