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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAiELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE /PERMIT CALL 209 953-7697 FOR1INSPECTIONS (E) IRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3 V 4 ` I✓� ! Y" /'?t -' G.1 CITYMP is r'6�' <br />CROSS STREET AP✓ II� O 1 <br />0 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME • L �+�'� »� i� t PH <br />OWNER ADDRESS 36 L r C"6 d L" -''- r'r L' L CITY/STATE/LP ♦ "1� V� t 2 <br />CONTRACTOR •' �'� •� N� Vtiyrt- Lrl A \J V**`e PHONE <br />CONTRACTOR ADDRESS !� • - 7 CITY/STATEIZIP 9t, �' " � i , C' C., e>�' <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br />LICENSE 7 C-57 VC -61 ❑ D-09 C Other NUMBER �� EXPIRATION DATE <br />DomESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE �jWomestic/Private C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 7 Soil Sampling/Characterization <br />Fl Public Water System <br />If different from Owner. Water System Name Contact Name or Phom Number <br />TYPE OF WORK 0 New Well ❑ Replacement Well 7 Well Alteration/Modification :3 Other <br />❑ Monitoring Well(s) # of wells 7 Soil Boring(s) sof bonngs ❑ Geotechnical # of bonngs <br />n Out -Of -Service Well -1 Out -Of -Service Well Renewal r- Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method n Mud Rotary r Air Rotary r Auger n Cable Tool n Push Point n Other <br />Proposed Well Depth ft Excavation in diameter C Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel ❑ Other <br />Grout Seal Depth ft U Neat Cement (94 lb bag/5-10 gal water) U Sand Cement sack mlx/7 gal water <br />U Bentonite (20% solids) U Other <br />Grout Placement Method ❑ Pumped C Free Fall r_ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By U Driller U Pump Contractor U Other <br />0 Concrete Pedestal ❑Dtmenslons: Width ft Length ft Thick in 0 Christy Box C Stove Pipe <br />Pmt MP Submersibles Turbine rl Other HPL 3 Pump Set % i ft Standing Water Level VA 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 ANACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS O ENSA WS. <br />I 8 A VANCE NOTICE REQUIRED FO]TQr9NSPECT ONS�PLEASE CALL (209)/95 7679 __ <br />SIGNED TITLE 1 • -e I r '� DATE h" lh ' ` I <br />D 0 P <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />PAYMEIv1T <br />RECEIVED <br />AUG 13 X021 <br />N JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ALTH DEPARTMENT <br />M E N T ©S ----7Y (///y ✓ <br />Date l � � I Area-------{--i—a Employee ID#Im <br />Date ❑ SPECIAL Well Permit <br />Data LIZ❑ WAIVER Received <br />Date Constructed Well Depth ft <br />MML=M <br />UFRMi <br />I <br />OUZIF ii//Nr/1�ES��L((F7L�l�ill <br />Permit/ <br />S I III <br />EHD 43-06 revised 4114118 <br />WELL /PUMP PERMIT <br />