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OCT 3 <br />65).1 .7860.21,Fr- WELL /PUMP PERMIT EHD 43-06 61110019 <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.S Ov.Gr /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS i k / i ti " <br />lip• 4N <br />CITY/ZIP , , . Ai r _ <br />I- <br />CROSS STREET .• .,,ii! . r . APN PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME . en ; n n 0 c K. L. ' A " IN C PHONE <br />OWNER ADDRESS 1-1 ' coc\AI., 0,y/sm./zip i t-L( \I'Vc 6`+‘ / et 5'203 ,1%) <br />CONTRACTOR /(1 e_,,k --e \ X. e_Nt- PHONE( 3‹,12 ) eil D ...12)44 <br />CONTRACTOR ADDRESS .0.‘ 44.. 11* i %AA \k 1. CrrY/STATFJZiP C-‘-'6 (V‘ 'WA / 1514 <br />SUBCONTRACTOR/CONSULTANT V k w \--, . • Vill• -3 p.019 .9 ) et (I\ . 7755 <br />SUBCONTRACTOFt/CONSULTANT ADDRESS ,'Ille-yc-A- 2,- cny/sTATErz.,61,-* c N / ct 56 32 ‘ 33 131 ) <br />LICENSE UK-57 0 C-61 0 0-09 0 Other NUMBER 4404.1_, EXPIRATION DATE LI / 3.1 240 0 <br />BILLING PARTY: 0 OWNER €.910NTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (439 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 lnigation/Agricultural 0 Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings 0 Geotechnical ter2_, #51 borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 3 Pump Repair C Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary C Air Rotary 6ger E Cable Tool C Push Point C Other <br />Proposed Well Depth V) ft Excavation in diameter 7 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />ii Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/9"age/ASTM Sched 3 Steel 3 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft aofieat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />H Bentonite (2.9% solids) C Other & <br />J Grout Placement Method ePumped C Free Fall 0 Other C Retardant / Accelerator (name) 4-- H PEDESTAL Installed By 0 Driller CI Pump Contractor 3 Other itt 7*/ . <br />u Concrete Pedestal uDimensions: Width ft Length ft Thick in L Christy Box L Stove Pipe <br />PUMP II Submersible i Turbine i Other HP Pump Set ft Standing Water Level ft <br /> V E D EC <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 />MINIMUM <br />SIGNED <br />HOUR ADVANCE NOTICE REQUIRED FOR INSPE TIONS - PLEASE CALL (209) 953-76971 <br /> TITLE e v DATE \\/ 1 11 <br />RONNIE <br />ERMI <br />019 <br />L HEALTH <br />VICES <br />TA <br />DEPARTMENT US ONLY <br />VI EN <br />TI SE <br />Area Date <br />Date <br />Date <br />Date ft Soil Boring Ins.ection By <br />COMMENT <br />Employee ID# <br />PECIAL Well Permit <br />0 WAIVER Received <br />Constructed Wel Depth <br /> <br />Application Accepted By <br /> <br />Grout Inspection By <br /> <br />Pump Inspection By <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />C ti <br />Amount <br />Remitted , te Permit/ <br />Service Request # Inv <br />n e , <br />AII9 ' , • <br />/ <br />• ... <br />A POO 0.2 37 kA I <br />EXPIRED