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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPAR WELLIPUMP PERMIT <br /> EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT INS CALL 209 953-7697 FOR INSPECTIONS <br /> ( <br /> JOB ADDRESS EXPIRES 1 YEAR FROM <br /> /DATE ISSUED <br /> _ CITY/ZlP nDN (iGU qL/-�llLlL__ r� <br /> CROSS STREET APN m <br /> OWNER NAME <br /> ', / PARCEL SIZE LAND USE APPLICATION# D <br /> r/�./ p <br /> p <br /> t"!Q- m <br /> OWNER ADDRESS Z D\l� �� m <br /> CONTRACTOR <br /> -I CITY/STATFJZIP <br /> I11?5�\p W^v/ <br /> PDH/-On,If/EI/(�'''�-/►�I�' <br /> CONTRACTOR ADDRESS /N <br /> CITY/STATMMOP-��J-�-�'�`-�+ <br /> SUBCONTRACTOR r <br /> PHONE <br /> SUBCONTRACTOR ADDRESS C�R�Y/5TATE/ZIP <br /> LICENSE y'*C-57 C-61 D D-09 L Other NUMBERUI�t 1 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391). Dibromochloropropane(4392)I_�.Arsenic(4393) <br /> INTENDED USE DomesticJPrivale D Irrigation/Agricultural C)Industrial ❑Water Quality Monitoring C Soil Sampling/Charactenzation <br /> ublic Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ,Other <br /> C Monitoring Well(s) #of wells [Soil Boring(s) n of boring' (I Geotechnical s of Donna' <br /> 0 Out-Of-Service Well i Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement J Pump Re air J Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'�Vud Rotary G Air Rotary F Auger f Cable Tool Push Point ❑ Other <br /> Proposed Well Depth_25) ft Excavation—11— in diameter "-Open Bottom :i Gravel Pack/Gravel Size in diameter <br /> C Conducto Casing in diameter / Cond for asing Depth It <br /> Weil Casing Diameter n Thickness/Gauge/ASTM Sched 7 Steel Plastic O Stainless Steel I l Other <br /> Grout Seal De th ft Neat Cement(94 Ib bagl5-10 gal water) O Sand Cement _sack mix77 gal water <br /> _ entonite V201/6 solids) Other <br /> r <br /> Grout Placement ethod umped G Free Fall C Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller G Pump Contractor Other <br /> Concrete Pedestal E.Dimensions Width It Length ft Thick in :1 Christy Box .1 Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> E IS <br /> CURRENT ANDN ACTIVE(WITH THE SCAL CALIFORNIA CONTRACTORSTATE LAWS, AND RULES STATE LICEINSE BOARD AND T THAT I AMT NYCOMPILIRED SIANCCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSP CTI t�NS-PL ASE CALL(209)953-7697 <br /> SIGNED TITLE \ -IL DATE <br /> 3J. qYM <br /> ,y F� <br /> ?011 <br /> CO <br /> aR IFN ry <br /> T <br /> DEPARTMENT USE ONLY <br /> �' Date - lq Area Employee ID# <br /> Application Accepted By <br /> Grout Inspection By Date= ❑ SPECIAL Well Permit V" <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENT J IPS P �? <br /> 1� C�17G��r. <br /> PE SC Received Check#/ Amount ata Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> L137J 9� / <br /> S� i2.? <br /> L -7:J <br /> EHD 4}ag llAt/t6 <br /> 2—F �� ) ��� WELL RUMP PERMIT <br /> 1 �(JT <br />