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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 />IVUIY-KEFUNDAB�L7E PERMIT www.slgov.orgtena EXPIR:5 1 YEAR FROMDATEISSUEC <br />JOB ADDRESS fJ( L� O� A/� R6 ! t o' � `'i is } 1 o V� I Gh i �. CITY/1JP .A Cam( C 1 C .h 1 7 °� 'RO <br />CROSS STREET C JCI I t C [r} ry 17 APN PARCEL SIZE ? AC LAND USE APPLICATION # <br />OWNER NAME `�� ` j 'U 5 PHONE <br />OWNER ADDRESS <br />CrrY/STATEMP <br />CONTRACTOR , L� 1 1 f n L� PHONEr✓�j1 <br />CONTRACTOR ADDRESS �. C� - iJG' 7E CITYISTATE17JP &C� \ LS -5'L!�.J <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SU13CONTRACTORICONSULTANT ADDRESS <br />LICENSE 'A C-57 o C-61 D D-09 <br />BILLING PARTY: D OWNER <br />CITY/S�tTATEZP ? <br />LJ Other NUMBER �I � t ) .5} EXPIRATION DATE -f — �1 <br />(CONTRACTOR L SUBCONTRACTORICONSULTANT <br />DoNlEsnc WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />WENDED USE DomesfclPnvate Ci Imgation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Charecterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C(Vew Well 0 Replacement Well 0 Well Alteration/Modification D Other <br />D Monitoring Well(s) # of wells ❑ Soil Boring(s) 4 of borings ❑ Geotechnical # of honngs <br />L Out -Of -Service Well 7 Out -Of -Service Well Renewal 'J Cross -Connection Repair <br />Drilling Method ' Mud Rotary 0 AlrRotary f; Auger D Cable Tool ❑ Push Point 0 Other <br />`Proposed Well Depth J z _�R p <br />p p ,� � �ft Excavation m diameter � Open bottom YGravel Pack/Gravel Size 1/ 4 in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _C� in Thickness/Gauge/ASTM Schad G -:?00 0 Steel ,Plastic 0 Stainless-teel 7 Other <br />Grout Seal Depth 4J it .7 Nest Cement (94 lb bag/5-10 gal water] )(Sand Cement I C _i sack mixR gal water. <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method Pumped D Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL 1 stalled By niter C Pump Contractor 11 Other <br />Concrete Pedestal Ll Dimensions: Width Zft Length ---I;/ ft Thick in ❑Christy Box [I Stove Pipe <br />PUMP { ,Submersible0 Turbine CI Other HP Pump Set JAS It Standing Water Level CIt <br />I HEREBY CERTIFY THAT 1 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 />r <br />J <br />PA TMENT U E O Y �/ <br />Application Accepted B ate Area Employee <br />Grout Inspection By Date ❑ PECIAL Well Permit <br />Pump Inspection By Date J WAIVER Received ,9 <br />Soil Boring Inspection By Date Constructed Well Depth Z'16- ft <br />COMMENTS <br />