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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIHUHMt31 I AL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> /� /7 7/ N <br /> JOBADDness / HO L7 "f �` /.S ✓� tCZ &1- C"U, (J ..7 C <br /> CROSS STREET 1 'G1,� S /APN_ ;J� Lj O J y' PARCEL SIZE S• H-LAND USE APPLICATION <br /> OWNER NAME PHONE A^� y//U� r! <br /> OWNER ADDRESS IZ�C •TV CrryISTATE/ZIP bos (/'`)J;qt l a-s�i !0-7 <br /> CONTRACTOR ,e / I lL PHONE Vi ) /QY 11 G1 3� <br /> CONTRACTOR ADDRESS �+/V Y�G 'r L /w� CrrYISlTATE/Zir J � (1 C I q Q I-S?((94 <br /> SUBCONTRACTOR/CONSULTANT ✓C][ Su�SJ�/r ,/�Lt'C.L�/�/�C/�y"/�rP'r'j� /��T( <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1 J1D r /G((�f Lr O( L/ CII VS 1 Al EIZIM I/t // 6 <br /> LICENSE JC-57 I C-fit il D-09 Other NUMBER EXFIRATCN DATE JJO 7J) v 2 Z <br /> BI:.LIHO PARTY: J OWNER ,gI CONTRACTOR SUBCO.NTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)JI Dibromochlcropropane(4392)[.]Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation(AgricLitural F Industrial ri Water Quality Monitoring 4 Soil SamplinglCharacterization <br /> PubQc Water System <br /> If difrerert from Cvmer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well I RePlacement Well `Nall ATeratlen/Modiflcatlo-I Other <br /> '1 Mon torngWell(s) #ofwells SoilBering(s', Nofbodrg3 Geotechnical7_Norw,�.7y <br /> J Out-Of-Service Well : Out-Of-Service Weil Renewal t:Cress-Connection Repair <br /> 7 New Pum 7 Pum Replacement ❑Pum Repair ;7 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _Mud Rotary -I Air Rdary J Auger Itj cable Tool _Push Pont -1 Other <br /> Proposed Well Depthft Excavation in diameter _ Open Eottom - Gravel Pack/Gravel Size in diameter <br /> J Conductor Casing In diameter / Conductor Casing Deplh N <br /> Well Casln9 Diameter_In Thlckre's/s/Gauge/A.STM Schad Steel Plastic "1 Stanle_cs Steel Oth Ar <br /> Grout Seal Depth I R +r Neat Cement(94 Ib bag/5.10 gal water) Sand Cement sack mix.7 cal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method JPumped jFree Fall -Other Retardant/Accderotor(name) <br /> PEDESTAL Installed By C Driller F Pump Contractor Other <br /> J Concrete Pedestal uDimenslons:Width N Length ft Thick In U Christy Box G Stove Pipe <br /> PUMP -1 S7lhmnmihla7 TurhinA lI Olhar HP Pump Sec fl Standing Water Level R <br /> I HEREBY CERTIFY THAT 1 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 RI COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I UM 48 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> AYMENT <br /> ECEIVED <br /> P202021 <br /> N JOAQUIN COUNTY <br /> _ ENVIRONMENTAL <br /> — 11 ACTH DEPARTMENT <br /> I 1 <br /> DEPARTMENT USE ONLY <br /> AplAicatiun Accepted By 'J L-"" eley/ / Area `.� Employee ID# <br /> Grout Inspection By } date Z r_ SPECIAL Well Permit <br /> Pump Inspection By Date G WAIVER Received <br /> Soil Boring lection By Dela 1 Constructed Well Deplh ft <br /> COMMENTS I/t�)'VIf�T Ifs F'I�t j:J �.fi L.f�F�C� j { r�vr'r"l-'� tllG%l7 S',� fF'f'1- :�r et i %7L 'IV'44r_" <br /> i5 F :(. i `fY: <br /> PE SC R ce ed heck#/ Amount Palo' Permitl Involoe# Well IDM <br /> Codes Info h RemittedIca a nest# <br /> t - <br /> CIID 4_-00 G1112979 <br /> �LW�LMR <br /> IPUNPPER <br />