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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.sjgov.org/ehd ,.EEX^PI�R^ELS�1^YEAR FROM DATE ISSUED <br />CT <br />JOB ADDRESS � CITY2AC,6 <br />IP 1 1►`VII 1 �a��� <br />CROSS STREET ��iI+I GY J APN I �`� I I/ '' I 1 PARCEL SIZE G LA�LICATION 4 <br />OWNER NAME U -r hL 14 PHONE <br />OWNER ADDRESS I^ /7 h b If t,Vida hr. CITYISTATE/z.P U1 <br />\/ <br />CONTRACTOR Ir 1 PHONE �/1'I",�7 I� 1 <br />CONTRACTOR ADDRESS CITY/STATEIZIP tTM I � 1-Iiii <br />- / I O V 9 , <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS C"Y/STATEQ/LP <br />LICENSE i C-57 _ C-61 D -D9 - Other NUMBER 38 3 EXPIRATION DATE / <br />BILLING PARTY: - OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391):, Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE 7 DomestictPnvate "! Imgation/Agricultural F Industrial I_ Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If dlfftrent from 0—: Water System Name Contact N— or Phone Number <br />TYPE OF WORK New Well C Replacement Well C Well Alteration/Modification S: Other <br />Monitoring Weli(s) of wells C' Soil Bonng(s) a of bO"eg, Geotechnical 'r °f bOri ep <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />'Drilling Method Mud Rotary -- Air Rotary - Auger - Cable Tool - Push Point I Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel ❑ Plastic = Stainless Steel - Other Li <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/610 gal wafer) '- Sand Cement —sackmi gal water <br />Bentonfte (20% solids) 0 Other "{>> <br />Grout Placement Method i; Pumped Free Fall Other i - Retardant / Accelerator (name) E^ <br />PEDESTAL Installed By -: Driller D Pump Contractor Other N . <br />i, Concrete Pedestal ._Dimensions: Width ft Length ft Thine in ❑ Christy Box i_! Stove Pipe <br />PUMP ?f(Submersible-i Turbine I- Other HP Pump Set -_L - tt Standing Water Level < ft <br />1 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 FOR INSPECTIONS - PLEASE CALL (209) 963-7697 <br />SIGNED � J��. '� T. Vi tr-r�l4 DATE <br />021 <br />Grout Inspection By Date 'SPECIAL W911 Permit <br />Pump Inspection By li :-,t. c ,0.,. r Date Uw'VLI ... WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth tt <br />COMMENTS �,,�f r-' I I 2'r .. i `,p,/ f'TJ / f- <br />�Z <br />EH043-06 8111=19 WELL RUMP PERMfT <br />�,� . 12-227 t�B,Z� <br />