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f <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES IYEAR FROM DATE ISSUED <br /> JOB ADDRESS (,{,��h�p CrTYMP N PON Vat qw u tp m <br /> CROSS STREET__V V r J 1�_FW' APN -�I O I PARCEL SIZE LAT SE APPPLICATITION 1111 (�-9212— <br /> y9o <br /> OWNER NAME G PHONE 1f►% Q 1(J/ 21 y <br /> OWNER ADDRESS /�►(1��•Ok NAVA 4- CfTI'/STATEZP ��pON�.nG�1,rAar�V��/JtT <br /> CONTRACTOR a�/I I <br /> is` y)III PHONE <br /> ry�A/''�J ZL/�I!��j✓��J_ <br /> CONTRACTOR ADDRESS 1 CITY/STATEILP ROYMI J0 r GA 0 J )11 I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE/ZIP 1..1�w� �1 _ <br /> LICENSE t,�ti-57 0 C-61 L)D-09 U Other NUMBER ExPiRAT,ON DATE V T--1 O-2,02' <br /> DOMEsnc WELLS ty LING:#General MineraUColiform Bacteria(43914 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE mestic/Private 0 Irrigation/Agricultural U Industrial Or Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water System _ <br /> If different from Owner Waler System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well 0 Well Aheration/Modification LI Other <br /> U Monitoring Well(s) #Of wells D Soil Boring(s) a of borings ❑Geotechnical s of borings <br /> U Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 17 New Pump ❑Pump Replacement U Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method W<ud Rota 0 Air Rotary ❑Auger El Cable Tool G Push Point 0 Other <br /> Proposed Well Depth Eft Excavation�_in diameter 0 Open Bottom Gravel Pack/Gravel Siz in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. in Thickness/Gauge/ASTM Sched 'D Steel Plastic ❑Stainless Steel (I Other <br /> Grout Seal Dep ja it n Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> ntonite(2 h solids) O Other <br /> Grout Placement Method umped 0 Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor C; Other <br /> U Concrete Pedestal UDimenslons:Width it Length R Thick in 0 Christy Box U Stove Pipe <br /> PUMP J Submersible0 Turbine ❑Other HP Pump Set <br /> 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 /> MINIMME NOTICE REQUIRED F R INSPECTIONS-PLEASE CALL(209)9(533-7697 <br /> SIGNED TRLEr I I�,e,I' I DIN N$r DATE <br /> RF YMF <br /> CFV�T <br /> UG�s ?o?o <br /> � iv <br /> �PyCO <br /> r E- /V Y <br /> q RW/vr <br /> DEPARTMENTy4SE NLY <br /> Application Accepted By .�i`_ ��"" Date C �'Sr& v� Area Employee ID# <br /> Grout Inspection By / .J Date ❑ 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 Check#/ Amount Data Permit/ Invoice# Well ID# <br /> Codes Info h Remitted Service u9st# <br /> il <br /> 470EHD 6}118 8/01118 � V- �}' ���,U ��� WELL RUMP PERMIT <br />