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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 /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS ZZEXPIRES 1 YEAR FROM DATE ISSUED� ON fW CIT"p LIt�(A K' G(/V • Q�fZ7W' m <br /> JOB ADDRESS ~ <br /> N 1; 4 Rdi. IID• Q1 D .,Z <br /> CROSS STREET APAN RA I PARCEL SIZE LAND USE^/AAPPLICATION# <br /> OWNER NAME _ A ✓� PHONE Y/�' /•��V�^•7`��/�� / N <br /> OWNER ADDRESS IIS CITYISTATE/ZIP <br /> C <br /> CONTRACTOR MAMIJ N PHONE Z� 1/A�7ii�'1����r <br /> CONTRACTOR ADDRESS I I CITYISTATE/ZIP Mo r ,�A• �-+y <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZJP1� <br /> LICENSE C-57 L C-61 o D-09 Cl Other NUMBER EXPIRATION DATE 1•T✓V' A^'�l <br /> DOMESTIC WELL SAMPLING:fl General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392),'-j Arsenic(4393) <br /> INTENDED USE n Domestic/Private Irrigation/Agricultural ❑Industrial Ll Water Quality Monitoring [I Soil Sampling/Characterization <br /> -iPublic Water System <br /> wner <br /> If different from OWater System Name Contact Name or Phcne Number <br /> TYPE OF WORKNew Well Imo'Replacement Well rI Well Alterahon/Modification G Other <br /> C Monitoring Well(s) #of wells I Soil Boring(s) 0 p1 bongs C7 Geotechnical 0 of bonngs <br /> IJ Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum n Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary U Air Rotary J Auger %:Cable Tool G Push Point ❑ Other <br /> Proposed Well Depth Wo ft Excavation ,1A in diameter ❑Open Bottom )(Gravel Pack/Gravel Size in diameter <br /> L Conductor Casing in diameter / Condu Ior Casing Depth it <br /> Well Casing Diameter s In Thickness/Gauge/ASTM Sched s Steel r,Plastic <br /> U Stainless Steel n Other <br /> Grout Seal Depth 00 CE Neat Cement(94 Ib bag/5-10 gal water) Sand Cement it•% sack mix/7 gal water <br /> ❑Bentonite(20%solids) L Other <br /> Grout Placement Method : umped O Free Fall D Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller D Pump Contractor ❑ Other <br /> u Concrete Pedestal❑Dimensions:Width ft Length ft Thick in �I Christy Box Stove Pipe <br /> PUMP ❑SubmersibleC Turbine D 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE O,]] • DATE <br /> PQ YMFNT <br /> - ----------- <br /> VFD <br /> PR 4 ?020 <br /> gQUI1 <br /> ————————— #——————— aROA/41 <br /> q RCEN <br /> e _d MWA <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date U '1 7ozo Area Employee ID# �H <br /> Grout Inspection By l(il Date Ze2c, 0 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Date Amount Data Perm if Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> WELL/PUMP PERMIT <br /> EHD 41-06 8/01118 <br />