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ardzip L col ci 5 )40 <br />PARCEL SIZE s S- LAND USE APPLICATION <br />PHONE gC9 -7c S -3o77 r e cA qS <br />PHONE --)C 1 .c - 7 7ci <br />\ CA 956,32 <br />CITY/STATE/BP <br />CITY/STATE/ZIP <br />El <br />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.SigOV.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />E 4-46,t-nt.y ) r\ <br />Ni.3ci Mein RAPN t.)C1.10.-10 <br />(If Ck 12105 <br />SAPc7VTP, 1603( 7‘(-, <br />\JC\ 1 DC% i\•,n3 <br />1).c., 13c z1 0 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE X C-57 13 0-61 - 0-09 D Other NUMBER i299 3 <br />EXPIRATION DATE 7 -3 1- --)? <br />BILLING PARTY: DOWNER )(CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DomEsTic WELL SAMPLING: L] General Mineral/Coliforrn Bacteria (4391) 2 Dibromochloropropane (4392) E Arsenic (4393) <br />INTENDED USE L.! Domestic./Private P Inigation/Agricultural D Industrial D Water Quality Monitoring LI: Soil Sampling/Characterization <br />P Public Water System <br />It different horn Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK P New Well E Replacement Well P Well Alteration/Modification :1 Other <br />n Monitoring Well(s) * of wells -_', Soil Boring(s) a of borings 7 Geotechnical <br /> a of borings <br />Out-Of-Service Well DI Out-Of-Service Well Renewal ,, Cross-Connection Repair <br />i_ New Pump .Y., Pump Replacement •J Pump Repair : Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary - Air Rotary P Auger _ Cable Tool E Push Point DJ Other <br />Proposed Well Depth ft <br />Excavation in diameter D Open Bottom 3 Gravel Pack/Gravel Size In diameter <br />L. Conductor Casing <br />in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel Plastic • i Stainless Steel Other <br />Grout Seal Depth It _ Neat Cement (94/b bag/5-10 gal water) _ Sand Cement sack mix/7 gal water <br />- Bentonite (20% solids) = Other <br />Grout Placement Method 5 Pumped LI Free Fall _ Other -1 Retardant / Accelerator (name) <br /> <br />A <br /> <br />1 <br />(LI <br /> ,44L <br />ilL <br />PEDESTAL Installed By . J Driller Pump Contractor I Other <br />-7 Concrete Pedestal ,iDimensions: Wdth ft Length ft Thick ILL Christy Box Stove Pipe <br />PUMP X Submersible Turbine P Other HP Pump Set ft Standing Water Level 1- C it <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 A CURRENT AND ACTIVE WITH E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH AL <br />WORKERS COMPENSATION LAWS. <br />THE <br />NIINIMUIVI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 E.0Cl V 1V r <br />SIGNED /547-1( iii:9" T TLE \.)., C f-- P ''..C.0 ., (-1 t 0 4- DATE 1 i ')(1 I 21 Fp° n <br />u u 4 41 2n ,, ,,, Qum, rs <br />OEI <br />ON" <br /> NTAL ' <br />JN. <br />g <br />i,, <br />r <br />'VI NT <br />I') <br />110 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date 1 <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By (4 suite.> I <br /> <br />Date <br /> <br />Soil Boring Inspection By Data <br />COMMENTS <br />Area ' Employee ID# <br />.I SPECIAL Well Permit <br />- WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received Chec k/I/ exec; <br /> '1' <br />Amount <br />Remitted Date Permit/ <br />Service Request?, Invoice # Well ID# <br />, ,... <br />iAL <br />4 77 2-1141:24 l'4004111(,,,Of i <br />EHD 43-06 6/11/2319 <br />ePti )2(-6.503i <br /> WELL/PUMP PERMIT