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r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> jJosADORess J.,( 3 Jg03 An Seen Jf d r Cm2m -r(Q Cam' C� <br /> CROSS STREET �N`�I�C f'11�/L1661� G� APN] d 0 39007� PARCEL SIZE 2,6 LAND USE APPLICATION# o <br /> OWNER NAME �\,1\t-.(_ /�. ��/1 / I/ PHONE <br /> OWNERADDRESS 23403 �/ICIIS°i) > r /� CITY/STATE21P 774ef> C`A•� ,Jay,✓ <br /> CONTRACTOR L t✓ft h U//,`jet' W a%1 �O! 111%'1�% PHONE�01/'(•?I7G'y ��!yb <br /> CONTRACTOR ADDRESS- —q - 7s- Ovnn YVl• CITY/STATEMP rl c�/'r✓L'1� C`� /S��/� <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCOwrRACTOR/CONSULTANT ADDRESS CITY/STATE/Zip <br /> LICENSE )(C-57 D C-61 ❑0-09 'Other NUMBER 11009.�261 I EXPIRATION DATE -2 <br /> BILLING PARTY: ❑OWNER ONTRACTOR 7 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:A General Mineral/Coliform Bacteria(4391)A Dibromochloropropane(4392)0 Arsenic(4393) <br /> S,Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> o Public Water System <br /> I!!- <br /> If dirferent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well ' Replacement Well iI Well Alteration/Modification D Other <br /> ❑Monitoring Well(s) #of wells C SoiI Borings) "borings Geotechnical y ofbolings <br /> 11 Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 5<New Pump ^Pump Replacement 0 Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling'Nethod-?­r�Mud Rotary G Air Rotary L Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 3 00 ft Excavation I in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ,�Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_�2_in Thickness/Gauge/ASTM Schad S 0"--�I U Steel ;CPlastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth(2/i=ft ❑Neal Cement(94/6 bag/5-10 gal water) XSand Cement /ill, sack mix77 gal water <br /> 1 Bentonite(20%solids) 0 Other <br /> GroutPlacementMethod Pumped 0 Free Fall U Other C Retardant/Accelerator(name) <br /> PEDEsrk1 Installed By 0 Driller D Pump Contractor ❑ Other <br /> 0 Concrete Pedestal ODirnensions:Width_ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ji.,SubmarsibleD Turbine a Other HP�_ Pump Set /L O ft Standing Water Level It <br /> I HEREI3Y 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953y-7697 <br /> ©SIGNED_ • z TITLE C.�A -e4 DATE /�— '2 t� <br /> t <br /> fc <br /> lull <br /> �I <br /> e <br /> 0 <br /> S EN�ND A T E — <br /> HEA I <br /> Appliraeon Accepted BY �" Gate 7 V J L JV Area! 9 Employee IDa <br /> SK <br /> Grenl Inspecion By Date SPECIAL Wall Permit <br /> Pump Inspection By Date WAIVER Received <br /> Salt eadng Inspection By Date Constructed Wall Dapth a <br /> COMMENT Sf[yLY•A t,JL S a ft Gt G4 yvllnrwtUYH WPI �L.II 1_k,, r �o ell':��n5 <br /> y�j11yM �10n� <br /> PE SC Received CheckNl Amount Date PermiU InvoiceA We111Da <br /> Codes Info Cash Remitted ervke Be oast If <br /> 80 05 W.2 <br /> 0 p a70 <br /> 3 1 /so 1• <br /> V.ELL pl1YP VERYIi <br /> ERa�]A6 &IlealY <br />