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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-REFUNDABLE PERMIT WWW.13100v.OTp1ehd _ EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS �)(� L ��) �1' of l fes�!,, [=— CITYIZIP 642nr <br />SS STREET n ~ APN <br />��ARCEL SIZEL.2!2--Af�ND USE APPLICATION # <br />IER NAME j xP/HONE <br />IER ADDRESS CITY/STATE/ZIP <br />TRACTOR t� 'PHONE( 'q <br />TRACTORADDRESS CITY/STATEIZI A <br />:ONTRACTORICONSULTANT PHONE <br />LICENSE ❑ C-57 <br />BILLING PARTY: <br />ILTANT ADDRESS <br />Ac- 6 D D-09 <br />❑ OWNER <br />CITY/STATE/ZIP <br />❑ Other NUMBER '� -' l' I EXPIRATION DATE <br />AONTRACTOR C SUBCONTRACTORICONSULTANT <br />DOMESnc WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE omestic/Private C Irrigation/Agricultural :; Industrial C Water Quality Monitoring E Soil Sampling/Characterization <br />'u Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well 0 Well Alteration/Modification ID Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) a of borings 0 Geotechnical • of borings <br />❑ Out -Of -Service Well D Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />%Q4ew Pump ❑ Pump Replacement C Pump Repair r Raise Well Casino <br />Drilling Method 7 Mud Rotary ❑ Air Rotary 0 Auger 7 Cable Tool D Push Point 'I Other <br />Proposed Well Depth ft Excavation in diameter G Open Bottom D Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Li Steel C Plastic D Stainless Steel Ci Other <br />Grout Seal Depth ft C Neat Cement (94 lb bag/5-10 gal water) C Sand Cement sack mixtf7 gal water <br />., Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped D Free Fall D Other Retardant / Accelerator (name) <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 />DEPARTMENT I'-- nNLY <br />Application Accepted By _ Do;.. S / Area ql6lei Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By �Date—\:NL ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed WelDepth ft <br />COMMENTS (' J ;J�) CJ C� S K / C•�1.� ©— C O z-' �% <br />EHD43-06 6MIM19 WELL /PUMP PERMIT <br />F A <br />NT <br />�D <br />0202, <br />vrUN ry <br />Nr <br />