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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPART WELL/PUMP PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT v4ww.sv.org/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS : ] 1 . \ . I :/1 . .. .� .f.% <br />CITY/Zip <br />CROSS STREET Ur t-tjr.}Vi ' r c ,r77 <br />US+APN _ / —UlG L—/PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME /'�I� <br />Z• <br />OWNER ADDRESS 1 5 PHONE � O o —� <br />I•7 � L <br />CIT/STATEIZJP <br />CONTRACTOR W PHONE I <br />-93j-371bCONTRACTOR ADDRESS IAJ(I (a( <br />1 CITY/STATE/Z1P <br />SUBCONTRACTOR/CONSULTANT N_ <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATEIZIP� / <br />LICENSE x C-57 C-61 L D-09 OtherI <br />NUMBER <br />Jib <br />V g 1Q ExPIRATION DATE L <br />BILLING PARTY; OWNERONTRACTOR <br />+�'C SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391), DibromochlOropropane (4392) Arsenic (4393) <br />INTENDED USE M DomeShc/Private C - <br />TYPE OF WORK <br />mga lon/Agncultural Industrial - Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name <br />Contact Name or Phone Number <br />j. w vveu Heplacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells i' Soil Borin s x of bonngs <br />Oul-Of-Service Well 9O Geotechnical 4of bonngs <br />L' Out -Of -Service Well Renewal _ Cross -Connection Repair <br />New Pump JL Pump Replacement G Pumn RA„air _ <br />Drilling Method Mud Rotary _. Air Rotary _ Auger Cable Tool Push Point _ Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched <br />Grout Seal Depth ft Steel - Plastic Stainless Steel Other <br />Neat Cement (94 Ib bag/5-10 gal evater) Sand Cement <br />Bentonite (20% solids) _ Other sack mix/7 gal water <br />!Grout Placement Method Pumped - Free Fall Other <br />= Retardant /Accelerator (name) <br />PEDESTAL Installed By _ Driller - Pump Contractor - Other <br />Concrete Pedestal Dimensions Width It Length ft Thick <br />in Chns[y Box Stove Pipe <br />PUfdF r Submersible _Turbine Other <br />g Water Level It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TPHE WORK WILL BEump Set ftDONE nINDACCORDANCE 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 />MI NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7-607 <br />SIGNED IZ �/�/J/%J _ <br />TITLE _ F /j ��' DATE 7 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />TMENT, U,SE N L Y <br />Date <br />Date <br />Date �5 Z <br />Date <br />f Employee ID# r ' <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />0 <br />H <br />D <br />0 <br />0 <br />m <br />y <br />�� <br />�'V�D <br />17202, <br />U/N co <br />UN <br />TY <br />p�4�TA L <br />f�NT <br />WELL /PUMP PERMIT <br />