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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 tlVYVVIr.S Ov.OI /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> & <br /> T I' En <br /> iJoeADDRESS �C J 0I3 an See Ad, <br /> n S� CITY2IP <br /> CROSSSTREET APN Or V��J�v�V PARCEL SIZE �`LG LAND USE APPLICATION# <br /> OWNER NAME o <br /> SC,� 1,,\//eC 14 ��� 0O// Ir PHONE e <br /> y�/ H <br /> OWNER ADDRESS 340 3 �L�(�nS�i) RJt CrtY/$TATE21P <br /> CONTRACTOR L t V rt A L ��`7 el' W eI1 �O/rl II%/1 <br /> CONTRACTOR ADDRESS 7 //Un/1 YY/• CITYISTATEILP / L <br /> SUBCoNfRACTOR/CONSULTANT PHONE <br /> SUBCONfRACTOR/CONSULTANT"DRESS CITY/STATE21P <br /> LICENSE (C-57 ❑C-61 C D-09 _Other NUMBER /60,7.;20 I EXPIRATION DATE <br /> BILLING PARTY:: ❑OWNER ONTRACTOR 3 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:AGeneral MinerallColiform Bacteria(4391))a Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE /0—KDomesticlPrivate U Irrigation/Agricultural ❑Industrial [I Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name a Phone Number <br /> TYPE OF WORK >CNew Well ❑Replacement Well i]Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells C Soil Boring(s) It of borings Geotechnical If of borings <br /> I Out-Of-Service Well ;Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> >LNew Pump ,,Pump Replacement ❑Pump Repair I-Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method-;(Mud Rotary ❑Air Rotary C Auger U Cable Tool ❑Push Point J Other <br /> Proposed Well Depth 3 00 ft Excavation I oZ in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well(rasing Diameter_in Thickness/Gauge/ASTM Schad 01'--�I ❑Steel VPlastic J. Stainless Steel U Other <br /> Grout Seal Depth_,qa h- ft G Neat Cement(94/b bag/5-10 gal water) Sand Cement /d r sack mix/7 gal water <br /> 9 Bentonite(20%solids) I Other <br /> Grout Placement Method>CPumped U Free Fail U Other I_'Retardant/Accelerator(name) <br /> Ck Installed By U Driller ❑Pump Contractor CI Other <br /> U Concrete Pedestal UDimensions:Width It Length It Thick in ❑Christy Box ❑Stove Pipe <br /> Pure esSubmarsiblau Turbine U Other HP�— Pump Set /J�ft Standing Water Level ft <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. 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 /> MINIM M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953/-7697 <br /> SIGNED_ * 6�o�1`- TITLE ©Cj/I •L�t� DATE <br /> t <br /> Ax <br /> t f <br /> el <br /> ve <br /> DN A <br /> Applieition Au:epled DY i /u e r w n I•Da1e.7 Area S Employee IDa S <br /> Grnat Inspedion By ___6__' Dale__ SPECIAL Wall Permit <br /> PumP 1-pectiol,By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Wall Depth ft <br /> S n rt 1 in, Iv✓�' J. eaYiltnjr <br /> COMMENTS .�i o: a h"Ppi•`• <br /> �3.111�IN.JL2]__QL._yu_ts-. F-r4A?_Lf n.IM l:• _CT-..�J et _SpL <br /> A PE SC Received Check#I Amount D.I. Permit/ Invoice ell ID# <br /> Codes htfo Cash Remitted _ arvice Re oast a <br /> 3tro os 5� ►lsa -IM o 0 <br /> 3c� 0 o _ ao <br /> 43 1 __ /so 1 1 <br /> YJELL I'UfpP PFPMIt <br /> E,In•ISW eI11Re 1f! <br /> �/laSr3�lIsZ- � llb��3�sb <br />