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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 PERMITCALL <br /> 1CALL 209 953-7697 FOR INSPECTIONS f? EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 2< 2 + fr r 5 1 ) 1 Y3 v+} �j II CITY/ZIP I�J ID U n m <br /> CROSS STREET i+ L" - <br /> APN �- I C�CS PARCEL SIZE ( �[ LAND USE APPLICATION# o <br /> OWNER NAME cjY'b PHONE Cn <br /> A <br /> + <br /> D <br /> OWNER ADDRESS 1�' • �� Info CITY/STATE/ZIP /fit(�r, CA ���544 <br /> CONTRACTOR ' 1j \LF{ `)( III bi r� , 11 1 YI i t r(I Moil <br /> S -2:- 1012-0 <br /> CONTRACTOR ADDRESS II `I f� .12fr, 9 CITY/STATE/ZIP J V 1 oilyl-)-t�C�t qs 5'5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:[-]General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: a er ys em Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method}[ Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other / <br /> Proposed Well Depth iL t' ft Excavation 7 L in diameter ❑ E.Open Bottom Gravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diame r _ry 'in Thickness/Gauge/ASTM Sched c ar' ❑Steel Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Nbento nite,(20%solids) ❑Other <br /> Grout Placement Meth? $Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br /> []Concrete Pedestal dimensions: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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697"'] <br /> SIGNED S—4LX' TITLE DATE <br /> G <br /> d <br /> � i <br /> n <br /> -� <br /> Q. <br /> DEPARTMENT USE ONLY s <br /> Application Accepted By Date 6, 17,_ Area / Empiovee 04 'T S lt)Ayet Cos <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins Date Constructed Well Depth ft <br /> COMMENTS ' do By 141111/ flkleZGi // 11 <br /> Ar <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 79 1 5-V 3 �HC . j by 276' <br /> /')'77V 5 <br /> EHD 43-06 8/01,16 WELL/PUMP PERMIT <br />