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/,ni_ !l.lb rN1-ttwl Scc,n 3-`i5-17 <br /> lir= 12'-12 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT A CALL.220,.9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> I (� 1146!1 ii -S✓r n,t Cm/LP -SA'r A*,- 9' �kc v_f <br /> �]J D <br /> CROSS STREET, G�// Yt'•C'f d APN S ''�'�`.SL�y�y PARCEL SIZE O• A/LAND USE APPLICATION# A <br /> OWNER NAME C4t�Sr LP! K-Ut 'l �rYn�J Pre VOU17M FlJ•Si7-lZ f CPH0NE'.,yQ y-/y�1�/��� II 7 N <br /> OWNER ADDRESS ,ty3t�D N. iF rs�11 ' //I�V�, �1'/e CITY/STATEIZIP S�Clf-- !j, (4 <br /> CONTRACTOR Nil/ tA• •'J rrU�r- ,..(��id V/f(Z G✓� s-tt7'M`'µh PHONE �1,'—d•7 V,7u��/ <br /> CONTRACTOR ADDRESS 90 t1'L y/�L�I�S�Y•�G.ti/ G"�'1/ CITY/STATE21P 5.2 l/l/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEfZyIP G <br /> LICENSE -57 EIC-61 ❑D-09 ❑Other NUMBER LG 4' EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water byStern Name Contact Nam or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well []Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) S of borings Geotechnical / x of bodngs <br /> El Out-Of-Service Well E]Out-Of-Service Well Renewal []Cross-Connection Repair <br /> El New Pump [jPump Replacement C]Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method []Mud Rotary ❑Air Rotary Wu ger Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth -k Excavation in diameter E]Open Bottom [I Gravel Pack/Gravel Size in diameter <br /> E]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickne Gauge/ASTM Sched ❑Steel ❑Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth it Neat Cement f94lb baa/5-'10 gal wa;er) ❑Sand Cement sack mixl7 gal water <br /> I <br /> E]Bentonite(20%solids) /1 / <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By C:]Driller ❑Pump Contractor ❑ Other <br /> El Concrete Pedestal @Imensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level fl <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 /> MINI M 4 HOUR TD NOTICE <br /> REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED L4 _ TITLE L%LQ/�L�l�l�Y f Ala DATE �3 <br /> Ch •e <br /> p, U1 <br /> H <br /> EP, RTMENT U E NLY <br /> Application Accepted B Date- Area Employee ID# <br /> Grout Inspection By Date ❑ <br /> PECI L Well Permit <br /> Pump Inspection By pate ❑ WAIVER Received <br /> Soil Boring Ins ection Date--e?! Constructed Well Depth ft <br /> COMMENTS - 3 <br /> PE SC Received Chec Amount Date Permit! Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> Z t70 o �1 S <br />