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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468J420 <br />NON -REF NDA LE PERMIT %CALL 2009 953-761a1N I4o. '. <br />97 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />OB <br />JAD ESS G n <br />L 1� t Z 4 T r �CrTY/Z P <br />r Ckirl + ,om MCv y <br />�+� <br />CROSSSTREET �!W t�Ll !\�.(- L} 1-(�Tr :APN ,{(/1-y�O' _3 PARCEL SIZE O- LAND US APPLICATION III <br />/��� L r' 1 I'7 <br />OWNER NAME 14\ 1� A1�' �^ Te' I� (\ `i'[I/��• /�" <br />OWNER ADDRESS // / V I ,-,rsTATE/ZIP U�YiY//',. ,'a \Lr/ [��r,/v� }(� r'i'Sj/Crc/ <br />CONTRACTOR !Y l ) !I G' 7T 9 PHONE ( 1 <br />CONTRACTOR ADDRESS (' �) BIC, �r�\ �(; I' -S t' ,f )� CT'/STATE/ZIP I +— ( ,4 9 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CRYISSTATE/ZIP z <br />LICENSE X' <br />l ...%�C-57 C-61 D-09 Other NUMBER FxPIRATION DATE t/-30 26tyf <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dlbromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestir�Pnvate Imgation/Agrlcultural InclUstnal Water Quality Monitoring J(Sal Sampling/Characterization <br />Public Water System <br />It ddfererr 1— Owner sealer System Name Conied Name w Phone Nombor <br />TYPE OF WORK New Well Replacement Well Well AlterauontModdication Other <br />Monitoring Wallis) # of wells Soil Boring(s) x of "'gs X'Geotechnical -3 4 of bor'"d` <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Reolacement Pumo Reoair Raise Well Casino <br />!Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point <br />Proposed Depth It Excavation L6r / in diameter Open Bottom <br />Conductor Casing in diameter I Conductor Casing Depth <br />W 11C D T <br />Other <br />m <br />e as ng iameter inhickness, auge 1 M Schad Steel Plastic <br />Grout Seal Depth j n XNeat Cemert (94 Ib bag/5-10 gal water) Sand <br />Bentonite (20% solids) Other <br />Gravel Pack,'Gravel Size In diameter <br />_n <br />Stainless Steel Other <br />Grout Placement Method )CPUmoed Free Fall Other Retardant ' Accelerator (name) <br />n i7 gal <br />00 <br />o <br />CV <br />'-t <br />L LL <br />S C. <br />I: <br />F <br />LL - <br />LU <br />W '� <br />.L ~ <br />of <br />cr W <br />>a <br />Z <br />LU <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions Widlh ft Length It Th,Ck in Christy Box Stove Pipe <br />PUMP Sunrnersible Turbine Other HP Pump Set It Standing Water Level <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 48 HOUnR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -//PLEASE CALL (209) /953-7697 J* Ey_ <br />SIGNED r 'X TITLE I r Z. 1' I,1rc1I'DATE <br />ti J yea <br />NCO <br />ti <br />I)- <br />-ffl�L- 3 — �0' % — 4 V� —1 --- <br />Ttio� gRFNO��ry <br />MFNT <br />PA TMUSEY / <br />Application Accepted By Date <br />Arno Employee ID# <br />Grout Inspection By Date PECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By .G Dale Constructed Well Depth ft <br />COMMENTS <br />���F1.lG�]�lll,�JI//�� •'�C.'L/l�l��]ICI�nl�illi�L' I� %� <br />iii■I��ir■�Yivr� � <br />EHD 43-06 r—sed 4/1411 a //�(�A y. 1I-' 7'� S S3D WELL HUMP PERMIT <br />