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WELL/PUMP PERMIT <br /> SAN.IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT N.. CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 1 CITY/ZIP �r I m <br /> CROSS STREET �-�. APNOwl PARCEL SIZE N LAND USE APPLICATION# <br /> OWNER NAME "` PHONEloi _30 —N o3 'cn <br /> ,n? <br /> OWNER ADDRESS -2 ! �� t I , bN `/� _Lntl C <br /> CONTRACTOR PHONE <br /> k' 31 <br /> V ^P�1HONEy l� 1A/('>�v^'— /' <br /> CONTRACTOR ADDRESS Va� CITY/STATE/ZIP V(L_ ©� c f e L��F�� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /� y <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATED, ` '-ZV V t <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE "Domestic/Private "Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK , New Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> El Monitoring Well(s) #of wells E]Soil Boring #of borings s) E]Geotechnical #of borings <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 E]Mud Rotary E]Air Rotary ❑Auger Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter&_ in Thickness/Gauge/ASTM Sched ?$Qteel [-]Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth Mft ❑Neat Cement(941b bag/5-10 gal water) Sand Cement 1 P sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Xpumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor � Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set_- ft Standing Water Level ft <br /> I 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 /> MINIMW 24 HOUR AQVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 j <br /> SIGNED TITLE 0 `l�t�i�� DATE 1-2- <br /> A 2 <br /> is <br /> 140 <br /> H+ 11111 412 _w :� <br /> J <br /> DE AR I MENT USE ONLY <br /> Application Accepted B Ah Date Area Employee ID#1_7�7 _rJ <br /> Grout Inspection Date Z l5 ❑ SPECIAL Well Permit <br /> Pump Inspection By Dabs ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS — <br /> _�Q'1,�JiA�G�z'.-��� <br /> PE Sc Received? Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 3�7wZ Z v <br /> 07 gz / UUDUD <br /> 000 Wi4ltp6 <br /> EHD 43-Of 8/01119) � WELL(PUMP PERMIT <br />