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T <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1808 EAeT HAZELTON AVENUE - STOCKTON CA 95205 - (209) 48!!-3,20 <br />NON-REFUNDABLE PERMIT <br />1k.. MENT U E <br />CALL 209 953-7697 FOR INSPECTIONS <br />EgqpXPIKLti '1 YEAR FROM UA It: I"UrU <br />Joe ADDRESS <br />�NnLY <br />Date `-y <br />clasp -T <br />ao u . CAL C1131304 <br />Grout Inspection By <br />Date <br />•APN I110— UgSII • 1 J <br />LAND USEAPPLICATION# <br />CROSSSTREET <br />Date <br />PARCEL <br />Soil Boring Inspection By <br />5r_' <br />,. 1mlDf- <br />Constructed Well Depth <br />PHONE <br />OWNER NAME <br />OWNERADDREss <br />V\ <br />- CrTY/STATFMP <br />�0{ <br />2`� <br />CONTRACTOR <br />PHONE ' <br />CONTRACTOR ADDRESS <br />CRYi$TATEZP <br />PHONE <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />Crry/STATTEIMP <br />Other NUMBER U L✓ <br />EXPIRATION DATE �' ✓�' �� <br />LICENSE C-57 ❑ C$1 <br />❑ D-09 <br />❑ <br />DOMESTIC WELL SAMPLING: O General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (43x3) <br />INTENDED USE DomesUdPrivate ❑ IrtigetloNAgricUltural ❑ Industrial D Water Quality Monitoring D Sol] Sampling/Chareclerization <br />Public Water System <br />If diff-rerd from Owner. Warr System Nana Contact Name W Pt.- Number <br />TYPE OF WORK ❑ New Well Replacement Well 0 Wel] AlteratlarUMDditication ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) a or bongs ❑ Geotechnical s of borings <br />D Out-OfServke Well O Out -Of -Service Well Renewal 0 Croas-Connection Repair <br />.— o......, n o....., o..a... ,.,..,, n P—n Renalr D Raise Web Casing <br />Drilling Method XMud Rote ❑ Air Rotary ❑ Auger 0 Cable Tool D Push Point ❑ Other <br />Proposed Well Depth R Fxr�vatlon12Y_ In diameter O Open Bottom ❑Grovel Pack/Gravel Size In diameter <br />❑ Conductor Casing In diameter / Condy -sing Depth it <br />ter <br />Well Casing Diame. In , Thlckness/Gauge/ASTM Schad I4Steel ❑ Plastic 0 Stainless Steel O Other <br />Grout Seal Depth LOU R ❑ Neat Cement (941b bag/5-10 got water) 0 Sand Cement sack mW7 gal water <br />kenlonR (20% solids) 0 Other <br />Grout Placement Method Pumped D Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />0 Concrete Pedestal ❑Dimenslons: Width ft Length R Thick In ❑ Christy Box ❑ Stove Pipe <br />PUMP d Submersible❑ Turbine 0 Other HP Pump SeL ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 />MINIMUM 48 HOUR A VANCE NOTICE REQUIRED FOR IN PE <br />IC n(Iy NIS <br />*- PP SE CALL (209) 953-7697 <br />3rnNen _ Trnz V I I I W I �V f., 1 V V DATE ' <br />ONION <br />i.���%%/int/i�sJR�f•����1[lti`1,L�II�Ici/��� <br />IF <br />R� MFN <br />IpR F/VSO <br />aQ 1 s7o7, <br />MFNT� <br />1k.. MENT U E <br />Application Accepted By <br />�NnLY <br />Date `-y <br />Area Employee ID# <br />. <br />Grout Inspection By <br />Date <br />D. PECIAL Well Permft <br />Pump Inspection By <br />Date <br />0 WAIVER Rewlved <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />it <br />COMMENTS <br />ONION <br />i.���%%/int/i�sJR�f•����1[lti`1,L�II�Ici/��� <br />IF <br />R� MFN <br />IpR F/VSO <br />aQ 1 s7o7, <br />MFNT� <br />