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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 www.s;jgov.or-q/ehd EXPIRES 1 YEAR FROM DATE ISSUTD <br /> _m <br /> JOB ADDRESS CITYIZIP /13 r-Ii <br /> A / L / D <br /> CROSS STREET APN 1�0 1 S PARCELSIZE` t ?— AND U PPLICATION# o <br /> �I/�(�J�/}�/')�[//'� m <br /> OWNER NAME PHONEL <br /> �1 Q <br /> OWNER ADDRESS .3 CITY/STATE/LIP {� <br /> CONTRACTOR ]]//''�� ����J/PPI/HH�OON(�E}CO?Oyy� //'/�✓��-3a/Z� <br /> CONTRACTOR ADDRESS ao CITY/STATE/ZIP6/(/�..I�+/�"LOQ i �S <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SU13CONTRACTORICONSULTANT ADDRESS tC�ISS,TAAATEEIZIP <br /> LICENSE k57 0 C-61 0 D-09 0 Other NUMBER74P EXPIRATION DATE <br /> BILLING PARTY: 0 OWNER ❑CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> It <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well 0 Well Alteration/Modification 0 Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Bodng(s) #ofbodngs ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary I]Auger ❑Cable Tool Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel ❑Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94/b bag/5-10 gal water) 0 Sand Cement sack mixf7 gal water <br /> ❑Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑Other ❑Retardant/.Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> ❑Concrete Pedestal❑Dimensions:Width it Length it Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ibubmersibleLl Turbine ❑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 DATE <br /> 11. 1 Ate <br /> z <br /> 1 Y <br /> 0020 <br /> Zo COU,T-1 <br /> �RTAt <br /> M'�NT <br /> DEPRTMENT UJIIE ONLY <br /> Application Accepted By Date-3Zr CY Area Employee ID#lm re,414, <br /> Grout Inspection By Data 7 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date <br /> (��,Z.�.O ❑ WAIVER R2C21Ved <br /> Soil Baring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE Sc Received rcheSkq Amount Date Permit/ Invoice# Well ID# <br /> Codes Info s Remitted Service Re uest# <br /> 4W% -0 <br /> So <br /> EHD 43-06 6111=19 WELL/PUMP PERMIT <br />