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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 PERMIT CALL 20 953-7697 FOR INSPECTIONS EXPIRES 1 Y AR FROM DATE ISSUED <br /> I, rn <br /> Joe ADDRESS l�;V+ur V� L� •IV i. "� --'i3- N�-- CInmP i <br /> n <br /> CROSS STREET '-�'�JYi�\�C Iryll'�'! pN r+'t�- �J IPA R/CEL SIZE Z�� LANl1 F PPUCATION# /` L�"7/ A <br /> OWNER NAME C t'U t )T•�. ` i I" r-1. t',yr� L .L. "PHONE f�'/v ��/- V L.tG in <br /> OWNERADDRESS 7Ej t f-'\r[.�VN']1y�-F'� � �,�' r " _ CI 1STATEIZJP7 1NMi11NV/1r t��0� <br /> CONTRACTOR ,.J n�+`��./1� �'Vi�. PHONE 3i� tL71--77,- <br /> CONTRACTOR ADDRESS �)�I� �l�"l.-�C yT �� CITY/STATE0PciAr� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATi t /I <br /> LICENSE -57 C-61 0-09 Other NUMBER 1-L0�i EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring -Soil Sampling/Characterization <br /> Public Water System <br /> IkifrereM from C—ir Water SyStam Name Contact Name or Phone Numtmr <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) #.f Wrn9' �OGeotechmcal—Z_#'f w-9, <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 ti Auger Cable Tool Push Point Other <br /> a <br /> Proposed Welt Depth (5-� h Excavation_�in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> C iN b Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 4-10 ftNeat Cement(94 lb bag/510 gal water) Sand Cement sack mix/7 gal water <br /> Bentonile(20%solids) Iher <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(names <br /> PEDESTAL Installed By Duller 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 Level It� <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIUM 29 iC}7R ADVANCE NOTICE REQUIRED FOR IINSPECTIQNS-PLEASE CALL(209)9P3-7 97 <br /> SIGNED V /U'� TITLE t'—'et 1 �1z.fT��'��'St DATE <br /> > y. <br /> 3 iii 10..i. <br /> R <br /> t >F $ <br /> ' !t C DUNTY <br /> ENV I E r <br /> PE PAR-1VIEP T <br /> E P T M E N T U S O L <br /> Application Accepted By Date �� Area t Employee ID#����� <br /> Grout Inspection By Date PECI Well Permit <br /> Pump Inspection By Date �Y WAIVER Received <br /> Soil Boring Inspection BA Date _ 5 Constructed W II Deptp tt <br /> COMM' NTS / til ' <br /> 0)6' <br /> rl <br /> PE D <br /> SC Rec ived Check#/ Amount Permits <br /> Codes Info B Cash emitted ate Service Request# Invoice# Well ID# <br /> 5-1 q -)0 1 <br /> EHC aJ-05 8.a i++5 'NELLPUMP PERMIT <br />