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WELL/PUMP PERMIT <br /> - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4664420 <br /> NON-REF NDA LE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AD E 9 " Q OU'' C~CRY21P L'L'r - e m <br /> CROSS STREET IJ W Cu t(\t - 1)��rt'T'�dPN ,Z)'j-4SO' 3 PARCEL SIZE�'(�`•7 ,rL"�Ay�-ND Ug APs AT/ION# J p <br /> OWNER NAME ��{\ A r �' ` AIF A �-4'-f ZNEt/y (/-.��D—ZS'S-- D A. <br /> °! <br /> OWNER ADDRESS !v. (:I7Y <br /> /,,, /STATE/LP �.�',�n `t//a(a/r✓/'q� �J <br /> CONTRACTOR J T- 1 PHONE(-2 7 I (Ci r' / J L2,0 <br /> -LLCONTRACTOR ADDRESS •� /IIJr 'J CRY/STATFJZIP C.J-qt <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATE/ZIP Cl—,30'- <br /> / z/' <br /> LICENSE rG C-57 C-61 D-09 Othef NUMBER E%PIRATION DATE `! ,-/y'-zozrJ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> F <br /> NDED USE DomestioPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Sod Sampling/Characterization <br /> Public Water System <br /> If d0omn1,from Owner W.I.r System N... C.m.d Nam.a Ph.-Numb., <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) 9 f Wrings XGeotechnical_ 3 b—ty, <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair LULL OHO V <br /> New Pum Pum Replacement Pum Repair Raise Well Casing > O = <br /> WELL CONSTRUCTION �V <br /> Drilling Method Mud Rotary Air Rotary )(Auger Cable Tool Push Point Other C'V LL <br /> rjy <br /> Proposed <br /> Depth it Excavation it/ in diameter Open Bottom Gravel PacWGravel Size in tliameter � w <br /> 11,c r I yii Conductor Casing in diameter / Conductor Casing Depth ft 0 = Z <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other D 0 W <br /> Grout Seal Depth�j ft <Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water Cr LU <br /> Bentonite(20%solids) Other T Z <br /> Grout Ptacement Method Pumped Free Fall Other Retardant/Accelerator(name) !off LU <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width R Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water LevelIt <br /> 1 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-//PLEASE CALL(209)953-7697^^ 40 <br /> Z <br /> SIGNED TITLE -. 1' a 1Aeei DATE &-Zc) ✓�-��� <br /> IT 74( �✓!✓ ?9 V 6 <br /> N�R QUiN ?101,y <br /> MFNr <br /> P A TMENT USE 004,JY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date..;�&/1& Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check*/ Amount Permit/ <br /> Codes Info Cash a itte Date o c o * Invoice* Well ID* <br /> EMD 63-06 raviseC 4l14IiB ��/ S3(/ WELL(PUMP PERMIT <br />