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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehcl EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I CITYIZIP /� <br /> 2�� Imo D <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATI'ON/# <br /> OWNERNAME Ct� --yP�HONE <br /> OWNER ADDRESS n/c✓/1 -��'rt (/ CITYISTATE/ZIP / <br /> CONTRACTOR ��,yj��. l�� t r��t PHONE !(J / / / C -7L <br /> CONTRACTOR ADDRESS ►/�( (� ���(C ,�� � /1 CITY/STATEIZIP� C(�'cJ !/k�S �41 Cl`?z5 z <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP _ <br /> LICENSE C-57 C-61 ' D-09 is Other NUMBER �i�!� EXPIRATION DATE 31 <br /> (BILLING PARTY: OWNER CONTRACTOR Ci SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) . Dibromochloropropane(4392)i I Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private U Irrigation/Agricultural LI Industrial ❑ Water Quality Monitoring :. Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number A <br /> TYPE OF WORK D New Well _. Replacement Well Well Alteration/Modification U Other �+ <br /> ❑ Monitoring Well(s) #of wells I i Soil Boring(s) #of borings U Geotechnical <br /> ❑ Out-Of-Service Well 1-i Out-Of-Service Well Renewal U Cross-Connection Repair JUN <br /> �� <br /> ❑ New PuinP um PReplacement '_ Pump Repair L1Raise Well Casing a V 9 <br /> WELL CONSTRUCTION "✓QA <br /> n­ <br /> ,Drilling Method L Mud Rotary - Air Rotary Auger Cable Tool ❑ Push Point Other A.ENV/ "Iov <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom illGravel Pack/Gravel Size DTdI meter <br /> ❑ Conductor Casing in diameter I Conductor Casing Depth ft FNT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ISteel ! Plastic i Stainless Steel ' Other <br /> Grout Seal Depth ft 1 I Neat Cement(94 Ib bag/5-10 gal water) i7 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method I1 Pumped D Free Fall Other ti Retardant I Accelerator(name) <br /> PEDESTAL Installed By U Driller I I Pump Contractor Other <br /> _ C Concrete Pedestal UDimenslons:Width ft Length ft Thick in :j Christy Box Stove Pipe <br /> PUMP '2 Submersiblel' Turbine U Other HP 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 COMPENSATIONWS. <br /> MINIMU UR ADV�AN ICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED � 7 /! TITLE -"z"' DATE <br /> I <br /> I <br /> i <br /> I <br /> c' <br /> A I <br /> ,r <br /> I <br />