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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />KUM-KEFUNDABLE PERMIT <br />GALL LU`J 903-10WIF FOR INSPECTIONS EXPIRES 3 YEAR FROM DATE ISSUED <br />Joe ADDRESS <br />I <br />YA <br />CITY/L1PI <br />CROSS STREET <br />} ' <br />I O PARCEL S¢E 4 Y 1�r LAND USE <br />(� <br />OWNER NAME V <br />'PN <br />DAlogo <br />1 W <br />'JAP}�PILIICATIONN�y## <br />PHONE ,0 t O✓( W VU <br />1, (� <br />OWNER ADDRESS 1 V <br />CITY/STATEILP -EGA ION, Ga% 6i 53� 7 <br />/�It1 C <br />CONTRACTOR a J <br />t0 <br />PHONE LA L -Z "' 2—1 <br />�//�� <br />CONTRACTOR ADDRESS 1A&E <br />CITYISTATFOP :J J <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CrrY/STATElZIP <br />LICENSE C-57 0 C-61 C D-09 <br />O Other <br />NUMBERUM i ExPIRATION DATE O+ • ✓ 0. ✓� I <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE DomesticlPrivate ❑ Irrigation/Agricultural n Industrial C Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner Water System Name Contact Name or Plane Number <br />TYPE OF WORK 0 New Well Replacement Well 0 Well Alteration/Modification 0 Other <br />C Monitoring We (s) # of wells ❑ Soil Boring(s) i of boring° 0 Geotechnical s of bonnpa <br />0 Out -Of -Service Well 0 OW -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method )(Mud Rota 0 Air Rotary 0 Auger �0 11Cable Tool 0 Push Point Cl Other <br />Proposed Well Depth _ft Excavation -rL in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size=JKW in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in . Thickness/Gauge/ASTM Schad 10 0 Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal DQpth r It ❑ Neat Cement (94 111 bag15-10 gal water) 0 Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method XPumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br />0 Concrete Pedestal ODimenslons: Width ft Length It Thick in 0 Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set 1t 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. 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED OVIFQR'It�S�'F,CTIIONS(-PLEASE CALL (209) Q53-769717Dik' <br />DEPARTMENT USE ONLY <br />Application Accepted By c_r/�- / z ' I•--- Date ✓ / Area d r / Employee IMA# �+ <br />Z 44- <br />Grout Inspection By e\ ❑ SPECIAL Well PermitPump Inspection By Date ❑ WAIVER Received Q / <br />Soil Boring Inspection BY Date Constructed Well Depth Z V � ft <br />COMMENTS S( L it 'tt Cti X11 i is /PPC F� (--• y" IJ ! "'E'ry i)/'•C C4'%lJL , �S <br />ZOZ.1 <br />EHD 43-08 8,0110 �l �, r , I �7 3 q / 36 2— WELL /PUMP PERMn <br />G�A�//EL�IPJ�IT.I�ir���� <br />EHD 43-08 8,0110 �l �, r , I �7 3 q / 36 2— WELL /PUMP PERMn <br />