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r r NELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY EMnRONI.tENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AvENuE - STOCKTON CA 95205 6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />WWW S OY.O @hd � /ELXP �R) E7�S 1/YEAR FROM DATE ISSUED <br />JOB ADDRESS! /^ CITYMP <br />STREET <br />NAME <br />ADDRESS <br />CrryiSTATEfZIP <br />wiv ,.wAr.r , , CITYiSTATE0P zy�,�_ a rJI..T4-C Kl� <br />SUBCONTRACTOR/CONSULTANT <br />PH <br />SUBCONTRACTOR/CONSULTANT ADDRESS C111Y�STAT7a/ZIP <br />LICENSE r C-57 ❑ C-61 0-09 U Other NUMBER �L <br />ExPiRAT1oN DATE I �i <br />'BILLING PARTY; O OWNER C CONTRACTOR '3 SUBCONTRACTOR/CONauLTANT <br />DOMESTIC WELL SAMPUNo; ❑ General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTBMOeo Llse jADomesukJPrivate� Intgatlon/AgdculturBl Industrial <br />Water Quality MoNttxing G Sail Samprrng/Character¢etion <br />Public Water System <br />if tllflarent from Ovmer. Water System Name <br />Corded Name or Phone Number <br />�r•n new vvea 7 Replacement Well 7 Well Alteration/Modification C: Other <br />Monitoring Well(s) #of Wells a Sail Boring(S) aorbaings ❑ Geotechnical <br />Wok borings <br />out -or -service Well o Out -Of -Service Well Renewal G Cmss-Connection Repair <br />L New Pumn ✓o,.,..., o..^r.._____. _ .. _ _ <br />Dr111rng Method �] Mud Rotary 1,: Air Rotary Auger = Cable Tool �, Push Point -- Other <br />Proposed Well Depth ft Excavation In diameter -1Open Bottom a Gravel Pack/Gravel Size <br />et <br />Conductor Casing In diamer / Conductor Casing Depthft in diameter <br />Well Casing Diameter _ in Thltdmess/Gauge/ASTM Schad r. Steel � Plastic Stainless Steel `Other <br />Grout Seat Depth R Neat Cement (94 Ib bag/5-10gal water) Sand Cement <br />Bentonite (20% Solids) Z Other sack mix17 gal water <br />Grout Placement Method ^ Pumped = Free Fall 7 Other <br />Retardant / Accelerator (name) <br />EDESTAL Installed By 7, Driller = Pump Contractor - Other <br />Concrete Pedestal C -Dimensions: Width It Length R Thick in 7 Christy Box Stove PI e <br />PUMP Submersible^ Turbine - Other Hp <br />Pump Sel ft Standing Water Level <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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />� A g. <br />Vp^ <br />U6 <br />/V7q i , <br />T'VeAlr <br />APPlication Accepted By` %//� 1r�le Ar <br />Employee <br />Grout Inspection By Date ❑ PECI L Well Permit <br />Pump Inspection By LCT" Date S� Z.g- <br />�� WAIVER R@C@iV@d <br />Soil Boring Inspection By Date <br />COMMENTS Constructed Well Depth N <br />— /ZI d Z 3 iq <br />WELL IPUrdP PERMR <br />