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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95206 -6232 (209) 4683420 <br />NUN-KEFUNDABLE PERMIT <br />tiV WW.9 <br />Ov.Of /e1T0 <br />tAPIKtb 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS 3 <br />C t C i- t � ( I Tl <br />CITY/ZIP /� <br />~ I 5 �p --'C% <br />( e, 1-)l I��' ; C <br />`� <br />�7 <br />CRO53 STREET J `� Y? '1� <br />Y� APN <br />- PARCEL SIZE r V <br />LAND USE APPLICATION # <br />j�� <br />OWNER NAME/�� ! _� t l M <br />}� C'� l'1 C' M -t C"i <br />PHONE <br />OWNER ADDRESS (�� i �. <br />CITY/STATEILP /� <br />/ <br />i'C CA q <br />f7/Q <br />\ <br />CONTRACTOR V -I I D L Y <br />Cit I I I//��l�11l <br />�t ¢ 7 70, <br />PHONE d0 1 4'(-^�I - <br />CONTRACTOR ADDRESS �_ C <br />ii L' X `I ..r <br />CrrY/STATE/LP �' <br />^^] <br />C', 1 ` C r\ G CJ j <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />ADDRESS <br />LICENSE XC -57 D "l D-09 <br />BILUNG PARTY: D OWNER <br />Crrr/STATE/IIP <br />C Other NUMBER EXPIRATION DATE <br />7-31-�� <br />i%�CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: J General Mineral/ColifoiTn Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE DomesticJPnvate - Imgation/Agricultural �_. Industrial G Water Quality Monitoring C Soil Sampling/Charectenzation <br />Public Water System <br />It different ftom 0-- Water System Name Contact Name or Phan. Number <br />TYPE OF WORK New Well -: Replacement Well _: Well Alteration/Modification L! Other <br />Monitoring Well(s) # of wells Soil Boring(s) A of bodngs Geotechnical M.f la"""gs <br />Out -Of -Service Well Out -Of -Service Weil Renewal.? Cross -Connection Repair <br />Drilling Method X Mud Rotary Air Rotary -: Auger Cable Tool Push Point - Other <br />Proposed Well Depth 6• `-) It Excavation I in diameter -i Open Bottom `K Gravel Pack/Gravel Size �� _ in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter � In Thickness/Gauge/ASTM Sched S.L?Lt,_ Steel X Plastic 7 Stainless Steel - Other <br />Grout Seal Depth )C�- ft - Neat Cement (94 lb bag/5-10 gal water) 'A Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ' Other <br />Grout Placement Method XPumped Free Fall ❑ Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By `Driller Pump ContractorOther <br />Concrete Pedestal CDimensions: Width ft Length ft Thick in r' Christy Box Stove Pipe <br />PUMP Submersible,'. Turbine Other HP__.!::)_ Pump Set__LQ It Standing Water Level 14C ft <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 />N1 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC{T�IONS PLEASE CALL (209) 953-7697 ^t j <br />SIGNED Z �CG`%�..�-dc�� TITLEy 'Cr - I t r 4 P O+ DATE 9- 1 9 - `� 1 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />r MENT USE ONLY <br />Date 1 �2 Area <br />Employee ID#� <br />ti 2- D <br />", % ate Well Per <br />r,1 Date WAIVER Received <br />Date Constructed Wall Depth L J R <br />rMMELEF"Nom 1111111111-41 <br />65V - r1l 1;-�9'22-2--�3 <br />