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(7,/WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (2091 4 6 63420 <br />�vu nuurte�s1�wy <br />Lff&A <br />'--w 12. . V <br />er!! CITY/Zip I -rid " `>45-Z <br />CROSS STREET Pete �jc <br />l/ <br />APN � OS'!�y*7 <br />---PARCEL SIZE -.AND USE APPLICATION7# <br />OWNERNAME J U 11 <br />�G Lt <br />L <br />C/ 1A it V ZA T �/ <br />PHONE <br />OWNER ADDRESS Y/�,, <br />Joe <br />CITYiSTATPJZU` <br />CONTRACTOR s` f"C <br />,y <br />! <br />A /gyp i�r� <br />1 97 4 _c0 rJ <br />CONTRACTOR ADDRESS <br />o <br />1 Vy�� � <br />yjPHHONE <br />i♦ iv J <br />CITYlSTATEIZIP <br />,SUBCONTRACTOR <br />�r^ <br />-_ Tri `}7- <br />�rj <br />PHONE <br />(%/�C�� <br />SUBCONTRACTOR ADDRESS 1 <br />S 4_t V <br />4_�i <br />CITY/STATEI7UP r—an C Z b 7 <br />LICENSEf, j' C-57 D C-81 <br />❑ D-09 <br />❑ Other NumsER <br />ExplRpTtaN DATe <br />UOMES.TIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4381)(7 DibromochlaroDrODane (43921 r1 Araenir•. 1A AI <br />INTENDED USE 0 DomesticlPrivale D irrigation/Agricultural ❑ Industrial D Water Quality -Monitoring Sbil Ssmpling/Characterization <br />0 Public Water System <br />U dffWenl {rom Ownor: MW aystem Name CanleLr Nameor Phone N,ernbw <br />- t, netane 11.nt even u vvelt Anerahon/MDDlucatfon n Other <br />0 Monitoring Walks). # of wells 0 Son Bodn9() a s orhodnes Geotachnlcala orbodnoi <br />� �_ <br />D Out -0f -Service Well ❑ Out-Of-SaMce Welt Renewal ❑ Cross-ConnecWn Repalr <br />Drilling Method D Mud Rplary D Air Rotary ❑ Auger ❑ Cable Tool Push Point ❑ Other <br />Proposed Well Depth_.. Z> 0_ft Excavation In diameter ❑ Open Bouam O Grave! Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Silted ❑ Steel 0 Plastic O Stainiess Steel ^u Other <br />Grout Seal Depth It 4 Neat Cement (94 /b bag/540 gat water} D Sand Cement sack m!x17 gal Water <br />0 Bentani�t"e! (20% solids) O Other <br />SIT <br />Grout Placement Method Pumped O Free Fab D Other O Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other <br />O Concrete Pedestal ODimensions Width ft Length ftThirk in 0 Chrlsty 8ox D Stove Ptpe <br />PUMP O Submersible❑ Turbine 0 Other HP Pump Set ft Standing Water Level It <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAOUIN CO�11NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT ANI ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE 80ARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COFMAAEENSATION,LAK tk _ <br />REQUIRED FOR 1 I ECTION - PLEASE CALL (209) 953-7697 <br />TITLE F'" DATE ti 'S - I <br />0 PARTMENT/,USE ONLY (� n nA <br />Application Accepted By Date q - � - I 0 Area "I ` Employee 1D# r `K i 11 C d <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER ReCelved <br />Soil Bating Inspection By Date Constructed Wall Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Info B <br />Check* <br />Cash <br />Amount D <br />Reritfthate <br />d <br />Permltl <br />Service Re nest# Invoice # Well IDM <br />L <br />1 S t-' <br />L <br />c <br />2 <br />EH043-06 aMI116 <br />LVELL,PUMP PERMIT <br />