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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 /> sJON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAJE ISSUED <br /> JOB ADDRESS ��r) L,}� C �-lL� (� CITY/ZIP 4 m <br /> ROSS STREET / APN DFl1 i v O i PARCEL SIZE .4 t� <br /> L LAND USE APPLICATION# S <br /> OWNER NAME / PHONN,EVV +•' 2-L. N <br /> OWNER ADDRESS / �'DL �/r!� CIN/STATE/ZIP <br /> CONTRACTOR1t PHONE3`� -/1/1 ZJ' <br /> CONTRACTOR ADDRESS �� ' /�d) CITY/STATEIZIP d <br /> SUBCONTRACTOR i2 I/ys­1 PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE XC-57 I.C-61 C1 D-09 II Other NUMBER ExPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE U Domestic/P6vat .1 Irrigation/Agricultural ❑Industrial I I Water Quality Monitoring I Soil Sampling/Characterization <br /> I Public Water System <br /> If dlfferenl from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK- New Well L Replacement Well ❑Well Alteration/Modification C Other y1 <br /> 11 Monitoring Well(s) #of wells I I Soil Boring(s) It of borings r!Geotechnical a •4 vjFj) <br /> ❑ u=ice Well [I Out-Of-Service Well Renewal f I Cross-Connection Repair <br /> ew Pum Il Pump Replacement 1 Pump Repair n Raise Well Casing1 2 f <br /> WELL CONSTRUCTION N JOAQUI <br /> Drilling Method bldvlud Rotary n Air Rotary [I Auger i I Cable Tool Push Point G Other HJe �ONM1+�Nry <br /> Proposed Well/Depth�C ft Excavation /9� in diameter I Open Bottom X.Gfavel Pack/Gravel Size �CP�f�bMllgger <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> r <br /> Well Casing Diameter 6_in Thickness/Gauge/ASTM Sched 2,'n I!Steel ><Plastic [1 Stainless Steel ❑Other <br /> Grout Seal Depth i 0 ft 1!Neat Cement(94 It,bag/5-10 gal wafer) Sand Cement sack mixf7 gal water <br /> I.1 Bentonite(20%solids) I I Other <br /> Grout Placement Method 'Pumped it Free Fall [I Other I 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By II Driller !I Pump Contractor I Other <br /> I''Concrete Pedestal i lDlmensions:Width ft Length ft Thick in II Christy Box I'Stove Pipe <br /> PUMP <Submersibles Turbine I Other HP Z- Pump Set ft 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 /> MINIMUM <br /> 48-HOUR ACE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /`^^ .U•L�_ TITLE DATE _I " <br /> L <br /> C <br /> T <br /> EP RTMENT USE ONLY <br /> Application Accepted ly Date ?/ / Area*1PEIAL <br /> Employee ID# <br /> Grout Inspection By 7 Date Well Permit <br /> Pump Inspection By Dale_ I 1 WAIVER Received <br /> Soil Boring Inspection By Date- Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> �,ojej, Info emitted Service Re uest# <br /> 11 2 <br /> r cry <br /> ERD 43-06 8/01116 WELL/PUMP PERMIT <br />