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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 20 953-7Q97 FOR INSPECTIONS EXPIRES 1 Y AR FROM DATE ISSUED <br /> G1 N <br /> Joe ADDRESS 5"M" 1'/f-! J9U1 ^' '�r3- �G�--� ' clryzjp <br /> CROSS STREET '1J'1i.-l4C •N-eh '1rAPN1 - `PARCEL SIZE W> wLiND F/ PLICATIO�NT# <br /> OWNER NAME <br /> a <br /> C, `{ t(� 1� <br /> OWNER ADDRESS \_- f•k.�NSN�F� �`C '�'r CI /STATE/ZIP! ij V t 7 <br /> CONTRACTOR 11� 1�� L/lu 1� �'V L.. PHONE 2-t+ LCf��- - <br /> CONTRACTOR ADDRESS �� L�)�ti{,t�\'�l/r tiT r� CITY/STATE/ZIP CA Nt I ;Z it-!yZ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ST[ATEIZIP <br /> LICENSE -57 C-61 D-09 Other NUMBER <br /> 1Zv lV`{ ExPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochlcropropane(4392) Arsenic(4393) <br /> [LNTENDED USE DomestiGPrivate Irrigation/Agricultural Industrial Water Quality Monitoring ySoil Sampling/Characterization <br /> Public Water System <br /> If niIf—M from 0—., Wale'Syslem 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 Bonng(s) a of bonngs 1DGeotechnical *.f t'—qy <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 111-Auger Cable Tool Push Point Other <br /> Proposed Weft Depth l'/-1-0 ft Excavation�_in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> 1-Vk1tp Conductor Casing in diameter I Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 1C It eat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 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 ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set h 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 OXIR ADVANCE NOTICE REQUIRED FOR INSPECTIPNS-PLEASE CALL(209)9p3-7197 <br /> SIGNED _ _Yl U' TITLE "V�'�'L 1 `-�S'f:j✓�'f 5, DATE <br /> 61 <br /> l r <br /> a !i CQ N <br /> ! I rNvj E IIIT L <br /> ENV I _ <br /> T-T-F-I <br /> E P T M E N T U S OIL <br /> Application Accepted By r Date v3Area t Employee ID#jj! <br /> Grout Inspection By Date PECI Well Permit <br /> Pump Inspection By ' Date WAIVER Received <br /> Soil Boring InspectionBy Date _ Constructed W II Deptrjhh It/ rl <br /> COMyM�-F��,N <br /> ^ <br /> TS �. ') - <br /> IJ_t..JLL--EX'S-fes - <br /> PE SC Rec ived Check#/ Amount Permit]Codes Info B Cash emitted Date Service Request III <br /> Invoice# Well ID# <br /> EH0 43-M 8,01,16 WELL-PUMP PERMIT <br />