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1 <br /> J. i <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 96205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALLFMNM _209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 2c5_712_n/ (/-� -/[y CuTy-,P (!�/ 9 N <br /> CROSS STREET E5eedoh ee llofO, APN(J-1 _ 02b- 'D D PARCEL SIZE ,LAND USE APPLICATION# Q o <br /> OWNER NAME O ' PHON/Ef nI- <br /> OWNER ADDRESS 1 CITYISTATE2IP tI 1`T. <br /> CONTRACTOR IN PHE Z Z- L <br /> CONTRACTOR ADDRESS CITY/STATErLP V <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATEMP <br /> LICENSE C-57 ❑C-61 ❑D-09 n Other NUMBERM421-- ExPIRATIONDATE <br /> DOMESTIC WELL SAMPLING:AGeneral Mineral/Coliform Bacteria(4391)kDlbromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 0 Irrlgallon/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Boll SamplinglCharaclerizalion <br /> n Public Water System <br /> If dtRerenl from O.vner. Weiler Syelem Nem, Conled Nome or Phone Number <br /> TYPE OF WORK )<New Well ❑Replacement Well U Well Allerallon/MadlOcatlon 0 Other <br /> 0 MonfOring Wells) III Of Wells O Soil Boring(s) sol bodnpe 0 Geotechnical eofborinp. <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal U Cross-Connection Repair <br /> ❑New Pump D Pump Replacement D Pump Repair n Raise Well Caning <br /> WELL CONSTRUCTION <br /> Drilling Method ud Role U Air Rotary ❑Auger Tn Cable Tool Ll Push Point ❑ 01 er <br /> Proposed Wall DeplhW_1l Excavation _In diameter D Open Bottom /`Gravel Pack/Gravel Siz In diameter <br /> U Conductor Casing In diameter / Conductor sing Depth R <br /> Wall Casing D(emetor In, Thickness/Gauge/ASTM Schad U Slael Plestic ❑Stainless Steel 0 Other <br /> Grout Seal Depth U It ❑Neat Cement(94 Ib bagl5-10 gaf wafer) ❑Send Cement sack mix/7 gal water <br /> ) <br /> Benlonile(20%solids) ❑Other <br /> Grout Placement ethod Pumped ❑Free Fall ❑Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Coniraclor ❑ Other <br /> ❑Concrete Pedestal ODlmensions:Width It Length ft Thick In ❑Christy Box ❑Stove Pips <br /> PUMP U SubmersibleU Turbine ❑Other HP Pump Set R Standing Weiler 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 /> MINIMUM 48 HOUR AD ANCE NOTICE REQUIRED F��n(((\���{{{\INSPM IONS-PLEASE CALL(209L3-7 <br /> SIGNED TITLE ,1,__1,11.��JJ��•„' --�� DATE 697, <br /> A <br /> IFIE A N Vok <br /> V <br /> DEPARTMENT USE ONLY ( A <br /> Application Accepted By <br /> //� Date ti�a�U Area _/`/ EmployeelD# <br /> Grout Inspection By <br /> Date ❑ SPECIAL Well Permit <br /> Pump Inepedon By Data O WAIVER Received <br /> Soil Boring Inspection By Data Constructed Well Depth It <br /> I <br /> COMMENTS <br /> PE SC Racolvad Chackitl Amount Data <br /> PormlU Invoice ff Well IDC <br /> Codes Info B Caeh Remitted Service Re uaet C <br /> j36E U <br /> 2_7 <br /> 0 I— :r.. .[i! ! L1,1IEE <br /> '-lv, <br /> WELL/PUMP PERMR Vv�•^��`������I <br /> EHD 4S08 6101118 /p'7 307 _ <br />