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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENU£-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-T89T FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �JOB;,DoRES$ 2s— C1TY72tp� <br /> b <br /> i CROSS STREET I. PN ._.. L PARCEL SIZE AND USE APFUCATiON k <br /> OWNER NAME <br /> 333::: r ' IQ-2. <br /> / �" ryYZOwNERAooRess d �I <br /> CONTRACTOR PHONE 7,eS �30--- <br /> --- <br /> -49�r62.t y� <br /> III CONTRACTOR ADDRESS.'300 S, it' Zy f _____ ..,......._ C1TyletATemp J•—4 ,k_.�_1p'�-->L17 L- <br /> ISuscoNraAcraR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS LCn Y&AT �py <br /> Lir-ENse Zt-57 GC-61 7,D-09 Other_ NUW*R '�f.?J �S E)(MRATION OATEwJ - <br /> DOMESTIC WELL SAMPUNt:i" Genera!MineraUCoiiform Bacteria(4391). Dibromor:hioropropane(4392) Arsenic(4393) <br /> jr�TpLADED UsE ;;� omesl crpnvate :<IrrigationiAgricuhural industrial I Water Quality Monitoring Soil Samplingi nor {j <br /> Public,Water System � ?� <br /> it dslMrrn2 firspn Owner: Woo,system Cmaaa Name a phone Num <br /> TYPE Of WORK /New Well t.'.Replacement Weil x!Weil Alteration-Mod,fication <br /> Monitoring Wall(S) 0 of wells I Sol!Barings).,,___._ rcr°oiins' Geotechnica <br /> Out-Or-Service Well Out-Of-Servrc:r Well Renewal C Cross Cor:netxion Repair 0 <br /> _ New Pump ;:,,Pump Replacement PUM.R� ?Raise Well Callng <br /> WELLCONi TR CT*N 'IR7,yE <br /> iorilling Method i-<.d Rotary '::Air Rotary i:;Auger ;'ClaNe Tool rush Point Other m <br /> Proposed Weil Depth :300 R Excavation diameter Open Bottom to-,Gravel Pack/Gravel Size in diameter, <br /> Conductor Casing - in diameter 1 Conductor Casing Depth r <br /> I Woi!Casing D,amete'r 6_in 7hicknessJGaugelAS7M SC1ed_W21„._ 'Steel ?+'<sisC ..Stainless Steel other <br /> Grout Seat Depth 1100, ft Neat Cement(94:b bnq>5-10 ge7 Water) Sand Cement sack mixt7 gal water <br /> r."F*ntonite(20%soft&) ':':Outer __ _.... <br /> !Grout Placement Method mlmd 1 Free Fall [.Other Retardant I Accelerator(name) ' <br /> _..._._-_.... ...._ __.. <br /> PEDESTAL Installers By Dither wfump COntrattOr Other 1 <br /> Concrete Pedestal:'Ohmmsiom:Width_ ft Length it Thick _ in Christy Box Stove Pipe 1 <br /> j IMP bmersibie Turbine [”Other u..,..__._ HP _.. Pump Set R Standing Water Level_4 <br /> I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCE'S, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REa )REO LICENSE is <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE 80ARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS VOMPENSATION LAWS. ! <br /> M INI OUR ADVANCE NOTICE REQUIRED FOR INSPEC]T�iON�S,�-PLEASE CALL(209)953-7699x7 py <br /> SIGNED TITLE L,78fh1 A!'d�✓' DATE /. ✓".�d <br /> i <br /> 0 lit <br /> l <br /> I ; i <br /> I 1 _ <br /> - - <br /> � <br /> ! <br /> /,r DEPARTMENT USE ONLY <br /> �y <br /> Application Accepted By '4 r i Date ( Area -� — Employee ID# 7/> ' <br /> SPECIAL Well Permit <br /> Grout Inspection By CPt u Date /Z 1 WAIVER Received <br /> Pump inspection By Date <br /> Safi Baring Inspection By Dalt Constructed Well Depth tt <br /> COMMENTS <br /> w _._............_...... <br /> PE SC Received het AmountI .__ PermlV Invoice# I Wait IDN <br /> Codes nfD sh Remitted 1 DaW Service Re uest# li <br /> 7 <br /> f <br /> EN0434M CV011+11 v.T,LL?PUMP PFP-VAT <br />