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WELL/PUMP PERMIT 1 ) ✓ ' <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NUN-KEFUNDABL(E VERMIT [� UALL !U9 95S-7687 FOR INSPECTIONS EXPIRES 1 YEAR FRO�M1 DATE ISSUED <br />JOB ADDRESS ���'2' ✓ `/� � f'S 4�t� J—I ` 1 _ C CITY/ZIP <br />LA <br />CROSS STREET CAL 1R/� a -1C`j -6N Z JC3 — �+0 (PPPARRCCEL SIZE LAND USE APPLICATION # <br />OWNER NAME tY �� Q� tyQ s <br />OWNER ADDRESS ..J`W`u� a�yUtri / �j[�ZZ�L S Ciji l <br />CONTRACTOR k t I 1A \ 11 (/j-- Dir 1 111 /1, 41! <br />CONTRACTOR ADDRESS PO P ��h j <br />SUBCONTRACTOR <br />11 PHONE <br />t:R ^/STATE21P � C L,I 1 L� C) <br />PHONE Curl) �I7 ^ qLH 0 <br />CRY/STATE/ZIP &A <br />PHONE <br />SUBCONTRACTOR ADDRESS C <br />CrITY/STATE/ZIP <br />LICENSE XC -57 C-61 D-09 - Other NUMBER ;. k V-7 r/ EXPIRATION DATE 6 7 L, —'19 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X 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 F Well Alteration/Modification Other <br />Monitoring Wells) # of wells y"98 h8affjg s [ of borings Geotechnical of borings <br />Out -Of -Service Well _ Out -Of -Service Well Renewal _i Cross -Connection Repair <br />New Pump Pump Reolacemenl Pumo Repair Raise Well Casino <br />Drilling Method i i Mud Rotary i 1 Air Rotary XAugeri-i Cable Tool I Push Point 7 Other <br />Proposed Well Depth 44e Excavation (C in diameter a Open Bottom Gravel Pack/Gravel Size in diameter <br />I i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 1_ Steel i Plastic i Stainless Steel i Other <br />Grout Seal Depth�ft Neat Cement (94 /b bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br />I i Bentonite (20% solids) : i Other <br />Grout Placement Method i Pumped ,'Free Fall L Other i Retardant / Accelerator (name) <br />PEDESTAL Installed By i ' Driller I Pump Contractor Other <br />i Concrete Pedestal Dimensions: Width ft Length ft Thick in I i Christy Box ' Stove Pipe <br />PUMP i Submersible i 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 />-,1/*IMUM 48 H044R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76971 <br />SIGNED r ✓� � TITLE LrR.\ 6 !j I",2 ( DATE <br />E� RTMENT U E NL <br />Application Accepted By �� Date Area 'C Employee ID# �" J <br />Grout Inspection By Date PECIAL Well Permit <br />Pump Inspection ByG Dale WAIVER Received <br />Soil Boring Inspection By EM Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 revised 4114/18 <br />Service Request#... <br />WELL /PUMP PERMIT <br />