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s <br />1 <br />• .UMP PERMIT <br />SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 IV V CITVZP V ::/ /'t/ <br />'AM <br />AL <br />CROSS STREET APN�' 1 1_ - ll tY O PARCEL SIZE a LAND USE AP/P[yLUCATIO�IN1 k P I' '�/ty'/ <br />OWNER NAME (� PHONE I V r `I 13 _ 9 1 V O <br />OWNER ADDRESS Z 1/ - �/ CRYISTATEZP�cicllpyllv�ylCA q53� <br />CONTRACTOR ' 1I �V PHONE <br />CONTRACTOR ADDRESS CITYISTATEZP Vt Z <br />SUBCONTRACTOR PHONE <br />SUBCONTRAOTOR ADDRESS CITY/STATE/7jP <br />LICENSE C-57 D C-61 U D-09 0 Other NUMBER 2Z ExPuuT10N DATE <br />DOMESTIC WEU SAMPLING: D General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE I ADmeSficfPrivste 0 Imigation/AgriwHural U Industrial 0 Water Quality Monitoring n Soil Sampling/Characterization <br />❑ 1bublic Water System <br />if different from Omer Water System Name Contact Name or Phone Number <br />TYPE OF WORK Il New Well Replacement Well 0 Well Alterabon/Modificabon 0 Other <br />D Monitoring Wells) 9 Of wells ❑ Soil Borings) s of bari"os U Geotechnical 0 of borings <br />D Out -Of -Service Well U Out -Of -Service Well Renewal D Cross -Connection Repair <br />G New Pump ❑ Pump Replacement U Pump Repair U Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ,<Mud Rot U U Air Rotary C Auger Cable Tool n Push Point 0 Other <br />Proposed Well Depth R Excavation J�_ in diameter ❑ Open Bottom IA Gravel Pack/Gravel Size in diameter <br />0 Conductor asing in diameter / Conduct C s ng Depth t ` R <br />Well Casing Diameter. in Thickneaa/Gauge/ASTM Schad �� G Steel Plastic ❑Stainless Steel ❑Other <br />Grout Seal Depth R [I Neat Cement (94 Ib bag/5-10 gal water) and Cement sack mix/7 gal water <br />Bentonite 20% solids) 0 Other <br />Grout Placement MIlithod Pumped D Free Fall 0 Other U Retardant / Accelerator (name) <br />fIQLtTAL Installed By D Driller G Pump Contractor ❑ Other <br />D Controls Poo Drig ❑DimorPump Width _ R Length 11 Thick in U Christy Box ❑Stove Pipe <br />PUMP C Submersible D Turbine U Other HP Pump Set ft Standing Water Level ft <br />I <br />HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANGE eN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSEHf IS <br />CURRENT AND ACTIVE WfTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD ANA TII Y r .. <br />WORKERS COMPENSATION LAWS. - <br />APPIICation Accepted By - ,r <br />Grout Inspection By Date 7"✓-' i•4 / / [ <br />Date Area l� e _ Employee ID# <br />Date <br />Pump Inspection By �� Cl SPECIAL Well Permit Soil Boring Inspection By I ) WAIVER Received <br />COMMENTS ` Date <br />-! , ,1fi—ri J /' / --�_ Constructed Well Depth Z� <br />EHD 4108 milla <br />�Lqlq�-2- >". WELL /PUMP PERMIT <br />