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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-REFUNDA13LEdPERMMIT www.sjgov.org/ehd /EXPIRES 1 YEARFROMDATE ISSUED <br /> CITYZP A <br /> JOB ADDRESS I 11 I � n� „ D' 1t1-N VL/ f <br /> C [� �bD <br /> CROSS STREET 1�r '� KI l "APN .%,J 1 t + ' PARCEL SIZE SSC... LAND USE APPLICATION# O <br /> OWNER NAME ^lS n 0 G,A` I {-I PHONE <br /> OWNER ADDRESS `^ \).-7a M` CA nZ\ n, }-�1 `J CITYISTATEZP Z/1�{ <br /> CONTRACTOR ��I I l Y L�>'.[r '1/'(1 rl (PHONE ;J C'/j -!(,L _� 1 <br /> CONTRACTOR ADDRESS �) L'/` CIT'ISTATE/ZIP \T`'1�I CA C� <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZJP <br /> LICENSE >,,'C-57 ><C-61 D-09 - Other NUMBER GI L 3 8 3 EXPIRATION DATE / —­)J <br /> BILLING PARTY: OWNER _CONTRACTOR -: SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:�.i General Mineral/Coliform Bacteria(439 1): Dibromochloropropane(4392).:Arsenic(4393) <br /> INTENDED UsE DomesbdPnvate - Irrigation/Agricultural C Industrial : Water Quality Monitoring - Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Conrad Name or Phone Number <br /> TYPE OF WORK XNeW Well Replacement Well 1 Well Alteration/Modification Other <br /> Monitonng Well(s) #of wells D Soil Borings) s of tonnes Geotechnical u of borings <br /> .!Out-Of-Service Well D Out-01-Service Well Renewal Cross-Connection Repair <br /> New Pump L Pump Replacement ❑Purnp Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method7(Mud Rotary Air Rotary -Auger - Cable Tool D Push Point Other <br /> Proposed Well Depth 7 { ft Excavation _in diameter I Open Bottom X Gravel Pack/Gravel Size 1/ - in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� n Thickness/Gauge/ASTM Sched C�.1C C - Steel ,K Plasbc Stainless Steel _ Other <br /> Grout Seal Depth D Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack m+x17 gal water <br /> Bernonfte(20%solids) Other <br /> Grout Placement Method -Pumped Free <br /> e Fail -Other Retardant/Accelerator(name) <br /> PEDESTAL Installed ByDriller Pump Contractor Other <br /> Concrete edestal"_Dimensions:Width _ft Length It Thick in Christy Box _Stove Pipe <br /> PUMP Submersible Turbine .:Other HP Pump Set ft Standing Water Level 0L� 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 /> MINI UU/M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963-7697 <br /> SIGNED �-�J �" TITLE \i.1 C e `GS 1 d C11 DATE <br /> RFq y/� <br /> Sep 0 FO <br /> \A z qQ�, ��71 <br /> OFpq��o�NTY <br /> 44171 <br /> J r <br /> DEPARTMENT USE ONLY <br /> br _ <br /> Application Accepted By � `�' Date C 3� �l Area �+ Employee ID# t <br /> II'. <br /> Grout Inspection By ��a:ye.51� Ueori�G Date /1 .. SPECIAL Well Pernik <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth l R <br /> COMMENTS ! tCt:Jir d ( . eTr <br /> L-'X15►t`r7a Jr ii • r enf,-.rr1 )vi �.-�r_ <br /> PE SC Received Check#! Amount Permit/ <br /> Info Cnah AemftDate ted Service Request# Invoice# Well IO# <br /> ilit, f fs1) J 2 <br /> �< 73 <br /> EHG A3-0e &1111019 WELL HUMP PERMIT <br /> 4%� --k / 987�a16 <br />