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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1101 a h koe- CITY/ZIP S+VCL 0 A 9 S L{� y <br /> m <br /> CROSS STREET APN O q-0(11-000 PARCEL SIZEd220 LAND USE APPLICATION# A <br /> r'v1AP'(ds a m <br /> OWNER NAME C A' a��CO 1P_HONE/ � /+ <br /> OWNER ADDRESS U 50 No r�K Ave CITYISTATE/ZIP S7y�-k_�/� (Q1 Qr lJ <br /> CONTRACTOR - I f 'N� _ PHH/ONE(��S2L'N2_9 <br /> CONTRACTOR ADDRESS I`q At rs CITY/STATE/ZIP/ !/r� -1 V / �t In./7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZI <br /> P <br /> / <br /> LICENSE C-57 C-61 D-09 Other. NUMBER b(a`_ EXPIRATION DATES-3/_Z_ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochioropropane(4392)i i Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> E ORK xNew Well eplacement Well :I Well Alteration/Modification I I Other CAn'_ <br /> a o <br /> III Monitoring Wells) #of wells I Soil Boring p of borings s) Geotechnica f borings�AI 1 <br /> Out-Of-Service Well Out-Of-Service Well Renewal 1)Cross-Connection Repair 'M 1 ' g0tn <br /> New PumpPumpReplacement PumpRepair H Raise Well Casing `%% C IJ <br /> I-MRSTRUCTION 11 gL RO M COV <br /> III thod / Mud Rotary Air Rotary Auger I.1 Cable Tool Push Point Other TMO N EN7-Ak <br /> po'gdWell Depth 2S O It Excavation t L in diameter Open Bottom XGravel Pack/Gravel Size iniWbneter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Is in Thickness/Gauge/ASTM Sched� _Steel �lastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> xBentonite(209/6 solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller XPump Contractor .. Other <br /> Concrete Pedestal;!Dimensions:Width It Length It Thick in I I Christy Box Stove Pipe <br /> PUMP Submersible I Turbine I I Other HP Pump Set It Standing Water Level ft <br /> 1 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. 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 /> i1�iQUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INV CTIONS-PLEASE CALL(209))9533--769977 <br /> SIGNED TITLE lie ^ ' DATE 4+` <br /> _ <br /> VV <br /> 1• <br /> f <br /> t <br /> DEPARTMENT USE ONLY th0 <br /> i L Q�y <br /> Application Accepted By (2"& Date W ( t Area l_/ Employee ID# Sc k <br /> Grout Inspection By r Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date �1 Constructed Well Depth it <br /> COMMENTS tA� -A L -A <br /> PE SC Received Amount Date PermlU Invoice# Well ID# <br /> Codes Info Cash Remitted Service R uest# <br /> 8 S4 ZD <br /> AiTr i <br /> EHD 43-06 M1116 WELL(PUMP PERMIT <br />