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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 20 953-7497 FOR INSPECTIONS EXPIRES 1 Y AR FROM DATE ISSUED <br /> I �I C rn <br /> JOB ADDRESS V1 NT (VrL. ') t N 3 . r' N- CITY/ZIP N) V` <br /> CRO83STREET -A) Cu''i iJ'tt OC Irk'-d[ PN I NA _ _`PARCEL SIZE �)) ,LAND F/ PLICATIONN# C U• A <br /> OWNER NAME N L A LLL 10 * _PHONE 1:� `��J V <br /> OWNER ADDRESS 11) 4- „'�- �' r �+Q� CI ISTATEZP�PPHONE'2-6 <br /> t ) V t��C4 1)-1043 <br /> CONTRACTOR 1t-� p6Lj--7� r_) <br /> CONTRACTOR ADDRESS �L?J 1 V�lirtA�I�V'G tiT r CITY/STATE/lip C.M-r \A <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADORESS CITY/STATE/ZIP 'r Q <br /> LICEN3E -57 C-61 -D-09 Othef NUMBER ji y—O- EXPIRATION DATE <br /> DOMESTIC WELL SAMPuNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDeo UsE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ;,,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 Other <br /> Monitoring Well(s) #of wells Soil BOdng(s) ►of bonngs 50Geotechnical a or"'rgs <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 Mud Rotary Air Rotary 01 Auger u Cable Tool Push Point Other <br /> Proposed Weir Depth�ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> iUb Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 1�,-�O ft INeat Cement(941b bag/S 10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) ther <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine 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. 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 /> MINI UM�2 R ADVANCE NOTICE REQUIRED FOR INSPECT] NS-PLEASE CALL(209)9 3-7 9,5 ¢ 7 <br /> SIGNED J�u'L.�' TITLE 1 'V�'Z'L 1 �f�✓�I 5r DATE 7 Zt <br /> R <br /> ZU 01 <br /> i C100 NtY <br /> ENV LNYIhONN Eq T <br /> T <br /> EP <br /> TMENT_US,e O L <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date PEC] Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring In§Zection B Date Constructed WejI Dept ft <br /> COM NTS `1 4 �c'!Q <br /> PE SC Rec ived Check#I Amount Per Date <br /> Codes Info B Cash emitted Date Service Re uest# Invoice# Well ID# <br /> EM0 43-06 1110-6 WELL rPUMP PERMIT <br />