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WELL/PUMP PERMIT <br /> 'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITvlLP 1152-3(P <br /> CR05S STREET P M3- AQ—13� p <br /> APN QP,A�RCEL SlIZE� LAND USE AAPPPLICATIONN## ,r,� t7 <br /> OWNER NAME LII I 4I N V'11 1 W I/tJl �j ( V PHONE ''l -LT Ir% 9 <br /> OWNER ADDRESS p y� CITY/STATE/LP <br /> CONTRACTORMAS4I S I i/ PHONE <br /> CONTRACTOR ADDRESS I,q r 1 1 1 1 CITY/STATEZP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/7JP <br /> LICENSE C-57 ❑C-61 F.;D-09 0 Other NUMBER EXPIRATION DATE - <br /> DOMESTIC WELL SAMPLING:❑General MineraUColiform Bacteria(439 1)Fi Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private NrrigatiorVAgriculitural ❑Industrial 0 Water puality Monitoring�EISOilampling/Charactarizalion0 Public Water System <br /> ���...ccclt'''dilleranl hom Owner Water System Name Ca Ptro Number <br /> TYPE OF WORK *ew Well D Replacement Well ❑Well Atteration/Modification ❑Other <br /> D`Monitoring Well(s) #of wells ❑Soil Boring(s) a of bo g U Geotechnical If of bo ing' <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Rot ❑Air Rotary D Auger ❑Cable Tool C)Push Point ClOther <br /> Proposed Well )�.d <br /> h _ft Excavation f�F—in diameter ❑Open Bottom Gravel Pack/Gravel Size n diameter <br /> ❑Conductor Casing in diameter / Condu or Casing Dep ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad� Steel D Plastic D Stainless Steel ❑Other <br /> Grout Seal Depthgitt D Neat Cement(94 Ib 15ag/S10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑BentonAa 20%solids) ❑Other <br /> Grout Placement Meth Pumped ❑Free Fall ❑Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor D Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in U Christy Box :]Stove Pipe <br /> PVMP ❑Submersible Turbine ❑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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM DVANCE NOTICE IRED FOR INSPECTIONS-PLEASE CALL(209)19153-'7697 0 <br /> SIGNED Who TITLE DATE US'-s+'? <br /> V <br /> VNT <br /> FO <br /> 406 10 20 <br /> TH 0,COV , <br /> J /DEPARTMENT USE ONLY <br /> Application Accepted By +�Z— C— 3 1 Area �f Employee ID# I /� <br /> Grout Inspect on By (% Date ,� Cl SPECIAL Well Permit ��Ti , <br /> Pump Inspection By Date �L�. ❑ WAIVER Received (,,�0ll�p� <br /> Soil Boring Inspection By Date Constructed Wel epth h <br /> COMMENTS 92C 1 7 <br /> PE SC Received Check#/ Amount Date Penn Invoice# Well ID# <br /> Codes Into B ash Remitted Service ReauestP <br /> + 3FctFADIMII <br /> EHD 43-M &/91119 <br /> ^ � WELL)PUMP PERMIT <br />