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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTI.t Er1T 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232 (209) 468-3420 <br />NON-REFUNDABLE mu <br />www.sjgov.org/ehd ��EX�P�I�RyE�S I YEAR FROM DATE ISSUED <br />JOB ADDRESS mu V1 �1/� Y'Ala g��, al •tM�iVn CITYIZIP 1711��1V� r 9�L� <br />CROSS STREET Mc, G and AUS A�PNN i �l� 430 PARCEL SILE a .q LAND USE APPLICATION # <br />OWNER NAME 1� I - PHONE <br />1_on% <br />OWNER ADDRESS 3�Iw Il/%*J �� 1✓� CVE CITY/STATE2►1P�Cycho CardvTIe. �S <br />CONTRACTOR 1 `t Galt <br />r rn� ) 41lq — %7 �10� <br />CONTRACTOR ADDRESS ' 1 2 f ' Q(C CITYISTATEMP Gal • I Q • t�t��%S� V 62, <br />SUBCONTRACTOR/CONSULTANT ��U (�V er A_ I�L.LL1Y,I-1. �.J / • �}rO f.,PH`ONE 010) ; 1 /_/�' / %4 <br />SUBCONTRACTOORRICONSULTANT ADDRESS. y O -S 6 �.Y I"krl {Art `VII ,CIITT•Y/STATE21P WQpi "..,CA, C� 5ioct' <br />LICENSE 1/ C-57 C,61 : 0-09 Other NUMBER 1 '� EXPIRATION DATE q I (0120 22 <br />BILLING PARTY: Li OWNER - CONTRACTOR . • SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:: i General Mineral/Coliform Bacteria (4391) -- Dibromochloropropane (4392) I Arsenic (4393) <br />INTENDED USE Domestic/Private -1 Irrigation/Agricultural �) Industrial C Water Quality Monitoring Vtoll Sampling/Characterization <br />Public Water System <br />If different from Owner: V10er Syme. Name Contact Name or Phone Number <br />TYPE OF WORK i- New Well - t Replacement Well ::. Well Alteration/Modification n Other <br />Monitoring Well(s) # of wells t_ Soil Boring(s) 0 of borings VGeotectmical 114a of bonny`' <br />Out -Of -Service Well i, Out -Of -Service Well Renewal Cross -Connection Repair <br />c New Pump t, Pump Replacement D Pump Repair D Raise Well Casing <br />WELL CONSTRUCTION// <br />Drilling Method ud Rotary i: Air Rotary i'1 Auger !.7 Cable Tool Push Point t) Other <br />Proposed Well DepthJQ- Ito It Excavation in diameter a Open Bottom :7 Gravel Pack/Gravel Size in diameter <br />! Conduct-, Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_in Thickness/ auge/ASTM Sched � Steel i.I Plastic ❑ Stainless Steel i! Other <br />Grout Seal Depth IA— LOD « 44Neal Cement (94 /b bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br />I Rentonita 120% solids) D Other <br />Grout Placement Mathoc imped Ir1free Fall Otheretardant / Accelerator (name) <br />PEDESTAL Installed By ! Driller ri Pump Contractor U Other <br />Concrete Pedestal ❑Dimensions: Width _ ft Length It Thick in Christy Bax I . Stove Pipe <br />PUMP <br />Submersible'! Turbine A Other HP Pump Set ft Standing Water Level ft <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 />Z, <br />DEPARTMENT USE ONLY �/�7LW,,,�� <br />Application Accepted By Z, - Date Area 5% " Employee ID# M <br />Grout Inspection By Dm 1 SPECIAL Well Permit <br />Pump Inspection By Date 1 WAIVER Received <br />Soil Boring In Ilion BV Date ^ Constructed Well Depth <br />COMMENTS __l_Ee 1(� 1't/ Op IJb'Pb /T Caf'P.DPr I 6 7 PP.� b'! �'/ rOUri <br />PE Sc Received <br />Codes Info <br />Check#/ <br />Cash <br />AE& <br />Date Permit/ Invoice # Well ID# <br />Service Re ueIt# <br />94 z7 <br />EHD43-06 WiIQ010 WELLIPUMP PERMIT <br />TY <br />NT <br />