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WELL/PUMP PERMIT <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSVIA cakANO CITY/LP GAlO ,A q,CI�YD <br /> _ A D <br /> CROSS STREET 1 DD rr APN PARCEL SIZE�gLAND USE APPLICATION# O <br /> OWNER NAME I V Z01.V <br /> w <br /> Z � <br /> OWNER ADDRESS - O O J CITY/STATEP ,,�\�I1IO,1 <br /> Y I PHONE Ct� �93m <br /> CONTRACTOR PHONE 2101-q21'y11`'(J <br /> CONTRACTOR ADDRESS ! CIT//STATE/ZIP ul 53 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/7jP <br /> LICENSE C-57 0 C-61 D D-09 0 Other NUMBER �WgW EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING-XGeneral MineraUCOliform Bacteria(4391) Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENoeD USE DomestictPrivate D Irrigation/Agricultural D Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization d �� <br /> Public Water System •, <br /> If different from Owner. Water System Name Comp Nama or Phone Number 1 ry <br /> TYPE OF WORK New Well n Replacement Well 0 Well Alteration/Modification U Other /V v/�D <br /> Monitoring Well(s) #of wells 0 Soil Boring(s) 0 of boriNs 0 Geotechnical s of borings O <br /> Cl Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair ' �OZ� <br /> 0 New Pum D Pum Ra lacement n Pum 0 Repair Raise Well Casin <br /> WELL CONSTRUCTION E <br /> Drilling Method Mud Rot ry ❑Air Rotary 0 Auger ❑Cable Tool n Push Point ❑ Other_ ('� ,r)�T 0 Eti V NTy <br /> Proposed Well th o fl Excavation�in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size�W in diameter DE R 7.7 L <br /> 0 Conducto Casing in diameter / Conductor Casing Casing Depth �/ fl ENT <br /> Well Casing Diameter. in Thickness/Gauge/ASTM Schad Ul/_ D Steel q PlasliC 0 Stainless Steel ❑Other <br /> Grout Seal Depth ft C Neat Cement(94 lb bagi5-10gaf we or) <br /> VO,Sand Cement sack mrx/7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method umped 0 Free Fall 0 Other D Retardant/Accelerator(name) <br /> PEDE3TAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> n Concrete Pedestal❑Dimensions:Width_ft Length It Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible0 Turbine 0 Other HP Pump Sel fl Standing Water Level fl <br /> E WITH SAN <br /> IOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BI ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> WORKERS COMPENSATION LAWS. OARD AND THAT IAM IN COMPLIANCE WITH ALL <br /> MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR <br /> yINS <br /> 1��(C�/T ONS-PLEASE CALL(209)953'-)7697 <br /> SIGNED TITLE�1 I 1 t/lJ 1 � DW W 1 DATE—M•0,y" <br /> N <br /> n <br /> a <br /> DEPARTMENT U E N L Y <br /> Application Accepted By C' Date 0 0120 <br /> du y L7 i <br /> Grout Inspection By Area `7 Employee ID#_�� <br /> Date�(� 17 'h^I <br /> Pump Inspection By O SPECIAL Well Permit <br /> �"t' <br /> Soil Boring Inspection By Dale�— 11 WAIVER Received <br /> CRMMENTS �, X,�. };� a 1 ( i Date Constructed Well Depth <br /> ft <br /> PE SC Received Check#/ Amount <br /> Codes Info ash Remitted Data Permit/ <br /> 344 1 0 e Ice Re uest# Invoice# Well ID# <br /> 341 010 <br /> �39Z /s`p <br /> 00` 3 L� <br /> EMD 43-09 8/01/18 <br /> WELL HUMP PERMIT <br />