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WELLIPUMP PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> 'I� CALL 209 953-7697 FOR INSPECTIONS (EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2 17L!hrr 1J�e��i ,,�/rJ(e I�L' CITYILP 1—s�C rG�� <br /> LA <br /> JOB ADDRESS L,. ,n <br /> CROSS STREET 5 L' qn AIle -/Z <br /> I/� D <br /> �� APN -1yPARCEL SfCE1'/• LAND USE APPLICATIONS o <br /> 5 --. 'T— fG�3�5'i3 w <br /> OWNER NAME t'►h YICS Holo).� PHONE L� m <br /> OWNER ADDRESS t.)CL4�YIe- CITY/STATEZP '15-SCu�Ur��1 <br /> CONTRACTOR Va. 11IG 11ro-i `c, PHONE 7-0-1. 1 15• (.0 <br /> CONTRACTOR ADDRESS/' /5100 SG LV'0_ 214' . CIT'/STATE7ZIP MAA''e!6�_ i CA <br /> SUBCONTRACTOR l/IcLff1C��• !,✓nr/�SeP1li .�/7.rl�l PHONE <br /> SUBCONTRACTOR ADDRESS I�(/yo �C t'!C- CITY/STATEZP I1(,�nI 4-L—ec'— <br /> LICENSE D C-57 C-61 U D-09 ❑Other NUMBER 1 DA27°I(o EXPIRATION DATE—81 3 I zo 2 <br /> DoMEsnc WELL SAMPUNG:D General Minerat/Coliform Bacteria(4391)D Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE bl Domestic/Private Iq,Irrigation/Agricultural a Industrial LI Water Quality Monitoring Ii Soil Sampling/Characlerizalion <br /> U Public Water System <br /> If daerenl from O—ec Wale,System Name Conlad Nang or Phone Number <br /> TYPE OF WORK ❑New Well a Replacement Well O Well Alleration/Modiffcation U Other <br /> O Monitoring Well(s) #of wells n Soil Borings) o or bermes LI Geotechnical s of boring. <br /> O Out-Of-Service Well a Out-Of-Service Well Renewal fl Cross-Connection Repair <br /> n New Pum Pump Replacement n Pump Repair i I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method O Mud Rotary O Air Rotary ❑Auger C Cable Tool n Push Point I I Other <br /> Proposed Well Depth ft Excavation in diameter n Open Bottom I Gravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad n Steel i i Plastic U Stainless Steel a Other <br /> Grout Seal Depth ft U Neat Cement(94 Ib bag/5-10 gal water) n Sand Cement sack mixf7 gal water <br /> C Bentonite(20%solids) I i Other <br /> Grout Placement Method ❑Pumped U Free Fall U Other 1)Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller U Pump Contractor i I Other <br /> u Concrete Pedestal UDimensions:Width R Length R Thick in U Christy Box n Stove Pipe <br /> PUMP submersible❑Turbine [I Other HP Pump Sal R Standing Water Level H <br /> II? <br /> CERTIFY THAT 1 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�HCYIRS <br /> THECALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP A W . <br /> MINI ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9953-7697 <br /> SIGNED '= / TITLE E'C� DATE <br /> Vp d <br /> 14QU/ 4 2�f9 <br /> N <br /> C <br /> O�pM���� <br /> 71' <br /> T <br /> E-P RTMENT USE f/�/� <br /> Application Accepted By Date AreaEmpbyee ID#) (►/ <br /> Grout Inspection By rT Date 1_I SPECIAL Well Permit <br /> Pump Inspection By Date LI WAVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amountfe PermiU Invoice# Well ID# <br /> Cocks Info Cash RemittedE)a ' Service Request# <br /> 1 <br /> EH04I-be fevf.ed 4114119 �/'� WELL/PUMP PERMIT <br />