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it WELL/PUMP PERMIT <br />or SAN JOAQUIN COUNTY ENVIRONIACUTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468-3420 <br />NON-REFUNDABLE Pr PUTT n <br />JOB ADDRESS <br />CROSS STREET APN i 11 3I �l I " I <br />Cl O� PARCEL SIZE 1 J , 3 LAND USE APPLICATION # <br />OWNER NALIE <br />PHONE <br />OWNER ADDRESS <br />CONTRACTOR <br />CITYISTATECLP�� <br />a <br />CONTRACTOR ADDRESS <br />PHONE -a <br />a� / � /``__� J/ �— <br />CIn/STaTE/L <br />SUBCONTRACTORICONSULTANT <br />PHo�p <br />LTANT ADDRESSSUBCONTRAC_C7NUIS�ATEMP <br />LICENSE 5O <br />i <br />C-61 _ 0-09 Other <br />NUMBE EXPIRATION DATED <br />BILLING PARTY: ._: OWNER <br />- CONTRACTOR J SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL S"PLING: General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392) Arsenic (4393) <br />crvuEO� t DOmeshrJPrtvate Imgahon/Agnc nju[dl Industnal Water Quality Monitoring F. Soil SamplinglCharaderization <br />_ Pubhc Water System <br />It different from owner. Water System Name <br />Con1aU Name or Phone Number <br />Tu <br />"mow wee Replacement Well =Well Alteration/Modificatlon <br />Other <br />Monitoring Wells) # Of wells -- Soil Boring(s) a of borings <br />Out -Or -Service W II Geotechnical a of borings <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />T. New Pump Pump Replacement _ Pumn P—i, _ ..... - <br />Drilling Method Mud Rotary Air Rotary _ Auger - Cable Tool Push Paint Other <br />Proposed Well Depth s <br />ft Excavation in diameter s <br />Open Bottom <br />Conductor Cesin p Gravel PacklGravel Size n diameter <br />9 in diameter / Conductor Casing Depth ry <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad <br />Grout Seal Depth Steel Plastic Stainless Steel 'Other <br />ft - Neat Cement (941b bagl5-i0gal water) Sand Cement <br />Benlonite (20% solids) = Other sack mixR gal water <br />3rout Placement Method G Pumped - Free Fall = Other <br />Retardant /Accelerator (name) <br />PEDESTAL Installed By -. Driller PUMP Coniracior - Other <br />- Concrete Pedestal uDlmensions: Width ft Lengthft Thick <br />in _• Christy Box _ Stove Pine <br />�•s aunmerslble _ Turbine = Other HP Pum Sel <br />I HEREBY CERWater Level It <br />T FY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BEDONENitandin ACCORDANCE WITH SAN <br />JOAQUIN CODCTIVEIWATM ORDITATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />NANCES, <br />CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WOR RSC MPENSATION� <br />DEPARTMENT USE ONLY J <br />Application Accepted By L_- L, Date �J �v� Area Employee ID# <br />Grout Inspection By Date - SPECIAL Well Permit <br />Pump Inspection By . l�ri i� 'foal Date _ <br />WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS(� Constructed Well Depth ft <br />v/z {/z Z <br />rn <br />rM <br />O <br />w <br />�YMENT <br />CEIVE® <br />1 4 2029 <br />,UUIN COUNTY <br />;ONMENTAL <br />DEPARTMENT <br />W.LL tPU1. P PERMIT <br />