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L t <br /> SMAI LL <br /> Z CAM WELL/PUMP PERMIT Nvw Yr <br /> OUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRE33 ` CITY/Zip _ m <br /> CROSS STREET V f I ✓APN �J� PARCEL SIZE�LAND US APPLICATION# <br /> OWNER NAME 614r` ��{f� {� PHONE <br /> OWNER ADDRESS Z,-JGVw S AH ,— ,12 /' CITYISTATE/LP / • �/i-y']+/'^j�'3�� <br /> CONTRACTOR Z�V-.eAy Zt� �l� PyHO�NEyWCII`_lX JZ <br /> CONTRACTOR ADDRESS M a-2K � kC' CITY/STATE/LP�y\ �VL� l a53�1 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRE33 'CIIITY//STATE/LP <br /> LICENSE /C-57 C-61 D-09 / Other li3O NUMBER-1 L Sq La EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED UsE Domestic/Private/Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If Wfferern from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bofing(s) 0 of h-mg` Geotechnical s m bonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary AT Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter JU in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94!b bag/5-10 gal wafer) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Instilled By Driller Purdp Contractor Other <br /> Concrete Pedostjkf Dimensiddps:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible a ine Ot er HP Pump Set ft Standing Water Level 10 f <br /> 1 HEREBY ER FY THAT 1 HA ;PROPAREb THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN CO TY ORDINANCWiN <br /> . AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURREN ACTIVE WITH CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE -C MPENSATIONM 48 HO TICE REQUIRED FOR I S,P/E111'C/T^`IONS-PLEASE CALL(209)953-7697 <br /> SIGNE / TITLE DATE <br /> h �b; <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date/0-7'� Area-e� Employee IDA <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date����(( ►► �� Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Checks# Amount Date Perm Invoice IIIWell ID# <br /> Codes Info B Cash Remitted Service Re uost# <br /> 4 <br /> EH043-M 6n r/ is Ol 1 q ::E L,1':MF PP PM IT <br /> -�` Uploaded into Accela <br />