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' <br /> `. r WELL/PUMP PERMIT rIECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT C LL 209 953-7 97 FOR INSPECTIONS EXPIRE I YEAR FR 7Q <br /> JOB ADDRESS "1 r7 �7n CITYMP ,� U " <br /> CROSS STREET APN,3��O"'-"/ % 1 NV&f`U"Ep�(I <br /> IN <br /> /'',/ r PARCEL SIZE. _ LAND USE APPLIGTION �uyr� TH <br /> OWNER NAME / /� �C 0. I,v m.Ca t V)� PHONE /- /l m <br /> OWNER ADDRESS _ CJ-1 vc_ v h t Z�tir17n CITY/STATE21P �7 <br /> CONTRACTOR PHONE) <br /> CONTRACTOR ADDRESS y�lJ. I h CITY/STATE/ZIP 1(e L 17 1 <br /> SUBCONTRACTOR _[//�5f' PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP J <br /> LICENSE �C-57 -1 C-61 ❑D-09 Other NUMBER 1'L � EXPIRATION DATE JA �O <br /> DOMESTIC WELL SAMPLING:i I General Mineral/ColNorm Bacteria(4391)C Dibromochloropropane(4392).1 Arsenic(4393) <br /> INTENDED USE XDomestictPdvate i Irrigation/Agricultural Industrial Water Quality Monitoring 1!Soil Sampling/Characterization <br /> .=Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1(New Well :5 Replacement Well L 1 Well Alteration/Modification i1 Other <br /> Monitoring Wells) #of wells n Soil Borings) #of bonngs 1 Geotechnical 1f of Iwdngs <br /> Out-Of-Service Well I I Out-Of-Service Well Renewal .I Cross-Connection Repair <br /> New Pump i I Pump Replacement I I Pump Repair 1 1 Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary 1.1 Air Rotary 1 l Auger '__Cable Tool a Push Point ❑ Other <br /> Proposed Well Depth360 ft Excavation /z in diameter ❑Open Bottom 1 1 Gravel Pack/Gravel Size in diameter <br /> F1 Conductor asing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter Y in Thickness/Gauge/ASTM Schad !Steel i Plastic Stainless Steel 1 1 Other <br /> ,,t Grout Seal Depth /C& ft (1 Neal Cement(94 Ib bag/5-10 gal water) i Sand Cement sack mixf7 gal water <br /> k Bentonite(20%solids) I I Other <br /> Grout Placement MethocLA Pumped 11 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I.Driller A Pump Contractor 11 Other <br /> Concrete Pedestal I iDimensions:Width It Length ft Thick in I_'Christy Box _I Stove Pipe <br /> PUMP Submersible'. Turbine r!Other HP Pump Set It 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRE T AND CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ;OR <br /> R OM ATILAWS. <br /> Ml, 48 O ADV CE NOTICE REQUIRED FOR INSPEgTIONS-PLEASE CALL(209)953-769,77 <br /> SIGNED TITLE /1"//`A DATE 1D L17/j� <br /> bN <br /> C��VNT <br /> ,Ncou <br /> IF <br /> 9 ?�18 <br /> MFNT <br /> D,� RTMENT USE O LY <br /> Application Accepted By tVy�/ ate /� Area Employee ID# <br /> Grout Inspection B ✓ e )C' (15!1'1 I I SPECIAL Well Permit <br /> Pump Inspection By e r i! WAIVER Received <br /> Soil Boring Inspection By Date (Constructed Well Depth ft <br /> COMMENTS W kjj - ' 0 rn/►I,A <br /> PE SC Received Check#! Amount DatePermit/ Invoice# Well ID# <br /> Codes Info By as _ Remitted Service Re uest# <br /> k ( <br /> LZ Z 0 Id <br /> 3�t <br /> EHD 43-06 revised 4114/18 WELL/PUMP PERMIT <br />