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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 <br />JOB ADDRESS 14600 W <br />CITY/7LP <br />EXPIKE5 7 <br />t <br />/ y 4� v <br />1014 <br />STREET �Yii0*n �0� <br />AP <br />�Q PARCEL SIZE LANG <br />USE APPLICATION <br />NAME <br />` <br />PHONE <br />////���� ////1111 <br />� <br />Z"jM�C�ajL�'[ <br />•�71�_\O�M,a <br />la <br />ADDRESS �� <br />Kvein"Ft <br />ldtry� <br />1SLkxkC_�I70,C <br />/S TE/LP <br />yQaR�/r.•�' <br />PHONE <br />1CTOR <br />omt-1 <br />Q <br />LCTOR ADDRESS %o N <br />It • <br />CRYISTATE/Z1P <br />S 4ti X&K . <br />� 75"11A <br />VTRACTOR/CONSULTANT V <br />IkW Willi V.A. <br />11IONEAOi-41-7700 <br />VTRACTOR/CONSULTANTADDRESS 1I <br />CITYISTATE/ZIP C-10,1* <br />. Ali' 45(03.1 <br />E )ILC -57 C-61 <br />D-09 <br />i.' Other <br />NUMBER7,20106f <br />EXPIRATIONDATE &I -,30 <br />40 <br />PARTY: �.� OWNER <br />xCONTRACTOR <br />_ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:: l General Mineral/Coliform Bacteria (4391) ... Dibromochloropropane (4392) �! Arsenic (4393) <br />INTENDED USE Domestic/Private -. Irrigation/Agricultural Industrial Water Quality Monitoring xSoil Sampling/Characterization <br />Public Water System <br />It different from (Tuner Water System Nam Contact Name or Phone Number <br />TYPE OF WORK :- New Well .- Replacement Well I Well Alteration/Modificalion -: Other <br />Monitoring Wells) # of wells _ Soil Boring(s) "of bonne XGeotechnical 2% *1 boring, <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud a Air Rotary )LAuger Cable Tool Push Point Other <br />Proposed Well Dep j�ft Excavation in diameter - Open Bottom i Gravel Pack/Gravel Size in diameter <br />C nductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter tfhickne;iyGauge/ASTM Schad Steel Plastic ! Stainless Steel . Other <br />Grout Seal Dept i b R eat Cement (94 to bag/5-10 gat water) Sand Cement sack mix77 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller i' Pump Contractor - Other <br />r I Concrete Pedestal _ Dimensions: Width _ It Length ft Thick in , Christy Box ❑ Stove Pipe <br />PUMP a Submersible Turbine .. 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 COMPENSATION LAWS. <br />MINIM 48 HOUR ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED A.- A �J TITLE ler •t& WWokrDATE 10-23-11 <br />1. <br />2019 <br />G. ARTMENT U E O L <br />V <br />Application Accepted By Date Area_ Employee ID# <br />Grout Inspection By Date <br />/�_//(/�f����/y SPECIAL well Permit <br />Pump Inspection By - Date ' - / • WAIVER Received <br />Soil Boring Inspection By I Date Constructed Well Depth ft <br />COMMENTS <br />EHD43-06 N1112019 WELL /PUMP PERMIT <br />