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WELUPUMP PERMIT <br /> • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I M EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4693420 <br /> A NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -�{- "4 y <br /> Joe At)oRE33 '� S CTrY121p � m <br /> CROSS STREET`TA�& O AAPN I � � EL USE PUCATIO1 Y ` <br /> OWNER NAME s S PHOtE, a l I a <br /> OWNER A.E. t J6 1 CITYISTATEOP <br /> CONTRACTOR �GA P+ 1 <br /> HO7tNE1,�/��3 <br /> CONTRACTOR ADOREss C TY/STATEMP (T <br /> . 1 J F9b,3,)— <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR AOOREss CITYISTATE/Z P <br /> LJcENsE X C-57 _ C-61 D-09 Other NUMBER 3 3 ExPIRAnON DATE 3 <br /> DOMESTIC WELL SAMPLING: General MinerallColiform Bacteria(4391)' Dibromochloropropane(4392),.:Arsenic(4393) <br /> INTENOEO USE Domesbc/Private [':Irrigation/AgricutWrel :: Industrial Water Quality Monitoring Soil Samphrig/Charaaerizimon <br /> Public Water System <br /> II dh1ffwd ham Cv ..' Water System Nemo Contact Name or Phone Number <br /> TYPE OF WORK New Well : Replacement Well :i Wed AtteratlonilModif cation Other <br /> Monitoring Welt(s) #of weds D Sod Boring(s) Y w berme. Geotechr ical 8 or ba hp <br /> Out-Ol-Service Well 0 Out-Of-Serwce Wed Renewal Cross-Connection Repair <br /> XNewPump Pump Replacement (I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Y,Mud Rotary Air Rotary '.: Auger Cade Tool Push Point Other <br /> Proposed Well Depth;L-,75 R Excavation in diameter Open Boftom �Gravei Padr/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth It <br /> Well Casing Diameter <br /> in ThicknesslGaugeIASTM Schad''! { IIftSteel Plastic Stainless Steal :::Other <br /> Grout Seal Depth _ft Neat Cement(94 18 bag15-10 gal wated J(Sand Cement 1 h 3 sack mixn gal water 111►►►��� <br /> Bentonite(20%solids) Fab � � a <br /> Grout Placement Method Pumped Free Fad G Other '-:Retardant 1 Accelerator(name) <br /> Fir Instnited By I(Dnder L.Purnp Contred Other ED J�o <br /> JS Concrete Pedestal :Dlmansions Wdth ft Length ft Thic in Christy Box l:Stove Pipe f � f <br /> PUMP Submersible.: Turbine Other HP Pump Set ft Standing Water Level it (' f 3 2d'j18 <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN SD LICE14SE IS v <br /> CURRENT AND ACTIVE WITH THE JOAQU N COUNTY ORDINANCES, SCALIFORNIA CONTRACTORS STATE LICENSETATE LAWS, AND RULES AND ABOARD AND THAT 1 AMI ALSO CERTIFY T INCOMPLIANCE MY WITH Al�lr �V1R � fib Nj y <br /> WORKERS COMPENSATIONMm R R��D-��V,AN-�CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(208)953-7697,�) 7y aAF''� T <br /> SIONEO � GL/U WY6"�' TIDE DATE <br /> -" <br /> PA T M E N T 'SE ONLY <br /> Application Accepted By ate Z" Area Employee IDA <br /> Grout Inspection By ' Date ...,Well Permit <br /> Pump Inspection By Dena .' WAIVER Received <br /> Soil Boring Ipspection By Date C cted 11 Depth R <br /> COMMENTS <br /> PE SC Received Chec .. Amount �b Perraw Invoiced Well ID# <br /> Codes 1 to sh iRemitted Service Request# <br /> 0 100 lika <br /> L i <br /> EHD 43-M-sod 4114M8 WFLL HUMP PERMIT <br />