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1� �V <br /> • WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT C l- 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2,U U � Z /,,� � (�f ' 7 T, <br /> JOB ADDRESS I 1 CITY/LP -L+ww_�f/J- v S �-" m <br /> CROSS STREET �� -�-c�Wit, APN L G S G J-V U - PARCEL SIZE 'v aL rcJ LAND USE APPLICATION# o <br /> OWNER NAME L L�L 'A�f'-'..�.-L PHONE N <br /> OWNERADDRESS 0�� ( V �j ��a'nl(f"'CO �ITYISTATy\�IP_..'� � //lhh <br /> CONTRACTOR <br /> �. <br /> C..C. PHONE �� <br /> {/ Z-Ll I,.(_ <br /> CONTRACTOR ADDRESS C)�, -- _ 1 -)-\.,;LL1.S"t -f i C��' �LL " CITYISTATE/ZIP -U t, C '�I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE 4 C-57 0 C-61 D D-09 0 Other NUMBERr �/ V�i '/3 <br /> EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392). Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private ❑Irrigation/Agricultural D Industrial U Water Quality Monitoring D Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well D Well Alteration/Modification 0 Other <br /> D Monitoring Well(s) #of wells U Soil Boring(S) #of borings Geotechnical 3 p of borings <br /> D Out-Of-Service Well LI Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New PUMD 0 Pump Replacement [i Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary &Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 10-I ' ft Excavation U in diameter 11 Open Bottom U Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Cl Steel D Plastic U Stainless Steel ❑Other <br /> Grout Seal Depth ft 0 Neat Cement(94/b bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> O Bentonite(20%solids) U Other <br /> Grout Placement Method 0 Pumped O Free Fall '1 Other f1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor n Other <br /> U Concrete Pedestal DDimensions:Width it Length ft Thick in 0 Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible❑Turbine ri Other HP Pump Set It 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 /> MI.11 UM 4 H`O D�7`(p',NCE NOTICE REQUIRED FOR I� SPECTIONS,-Jq�LEASE CALL(209)953-7197 <br /> SIGNED i��lil,l /(A ��f^ TITLE -'��Y" Li'�I DATE I' <br /> / <br /> O qL <br /> LLL1 11 1 . 1h 0 R N <br /> M <br /> t 1 DEP,AT USE ONLY <br /> Application Accepted By�yJf�-{/r` \- + rn _pate .f= Area Employee ID#!?�•^ - I"N <br /> Grout Inspection By ` J Date IJ SPECIAL Well Permit; <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By- La Date /i `1 + Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 8 as Remitted Service Request# <br /> I 2 riiS E �i 'r t' <br /> EH043-06 8101116 WELL/PUMP PERMIT <br />