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i <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY NVIRO ENTAL HEALTH DEPARTMENT 1068 EAST HAZELTON AVENUE-STOCKTON CA 96206-6232(209)468-3420 <br /> NON-REFUNDABL PER WWW.sjgoy.org/ehd EXPIRES 1/Y�EA//jR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP I41ON I A g02-6 r-li <br /> �7r D <br /> CROSS STREET 1r aw' APP 224-190-001-PARCEL SIZE`✓� LANDIUSF.APPLICATION <br /> r�#/y� n/-Q 1nr 9 <br /> OWNER NAME 1 , 1 pq 11� PH <br /> ONE�A - I �O, q <br /> OWNER ADDRESS CITISTATE/ZIPV ,M�• "x—QLl�5JAO�32r0 <br /> CONTRACTOR PHONE 5:2 CONTRACTOR ADDRESS CITY/STATE/ZIP W . CA � <br /> jI <br /> SUBCONTRACTORICONSULI ANTE Uq' 91'Z•147-lb <br /> du <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE YC-57 D C-61 CI D-09 U Other _ NUMBER�Q� EXPIRATION DATEZ�Z <br /> BILLING PARTY: i I OWNER 11 CONTRACTOR I SUBCONTRACTORICONSULTANT 1 <br /> DOMESTIC WELL SAMPLING:1 1 General Mineral/Coliform Bacteria(4391)t I Dibromochloropropane(4392 1T_Arsenic(4393) <br /> INTENDED USE U DomesticlPrivale Irrigalion/Agricultural 0 Industrial 0 Water Quality Monitoring D Sail Sompling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water Splem Name Conlect Neme or Phone Number <br /> TYPE OF WORK ew Well 0 Replacement Well 0 Well AlterationlModilication U Other <br /> O Monitoring Wells) #of wells I]SMI Boring(s) x or bodnps 0 Gedtechnical_ x or borings <br /> I Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connectlglln Repair <br /> (3 New Pump U Pump Replacement 0 Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary 0 Air Rotary 0 Auger 0 C;ble Tool 0 Push Polnl 0 Other <br /> Proposed Well Depth2(,20 It Excavation_ in diameter 0 Open Bottom Gravel Pack/Gravel SIz in diameter <br /> 0 Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_L in ThCkness/GaugelASTM SChed i t]Steel Plastic n Stainless Steel U Other <br /> Grout Seal ",(Bentonite <br /> D Neal Cement(94 Ib bag/5 10 gal water) U Sand Cement sack mfxl7 gal water <br /> ,(Bentonite(20%solids) 0 Other <br /> Grout Placement Metl)od)(Pumped D Flee Fall 0 Other_ 0 Retardant I Accelerator(name) <br /> 1 PEDESTAL Installed By 0 Driller Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimenslons:Width ft Length It Thick in 0 Christy Box U Stove Pipe <br /> rPUMP 0 Submersible Ll Turbine 0 Other HP Pump Sel ft! Standing Water Level fl <br /> I HEREBY CERTIFY THAT.1 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 /> MI 48 HOUR A V E NOTICE REQUIRED FOR I`N•r�1SP CTIONS-PLEASE CALL(209)963-`7e•1697a <br /> SIGNED TITLE O\,9 DATE 1�'1`e <br /> S <br /> -17 <br /> lyfffi� I L-L <br /> 91 <br /> 01- <br /> Z <br /> CtN <br /> EE ARTMEN'TT USE <br /> ONLY { j��yJ,(/��J <br /> Application Accepted By Dale l/A1yJJJ�[ Area_� �1"! Employee ID#�� � J�:r - " <br /> Grout Inspection By— Dale (11 _ { 11 SPECIAL Well Permit <br /> Pump Inspection By Date Ii WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth _ft <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes 0 B ash emitted Service Re uest# <br /> 2"i 1awobA 3 <br /> WELL/PUMP PERMIT <br /> EHD43-06 GM11201V <br />