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A <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> 1 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 11PD�_ <br /> 364 E . Co CITY/ZIP �A_ GAY'•' 9S2/57 m <br /> WN-100- 610 <br /> pD <br /> CROSS STREET Z)1h*^t uv% _—APN U3'ZO a- V 10 PARCEL SIZE G3.O LAND USE/APPLICATION# <br /> ?- G O <br /> OWNER NAME ,t V t>oA1-(r6 PHONE C 1�'7 <br /> n <br /> OWNFA ADDRESS w1 Iadl G� t� !1 /'2.sI- CITYISTATEIZIP <br /> CONTRACTOR Mast111S Oft111N -In", �/� PHONE <br /> 52^Z'- 1gZff-1 <br /> CotrTrACTOR ADDRESS 1� 19 A ibcrS "L CITY/STATE/ZJPA I_ Oded7* (A <br /> SUBCONTRACTOR PHONE <br /> I <br /> SUBCONTRACTOR ADDRESS CnY/STATE/ZIP _ <br /> LICENSE Xr C-57 f, C-61 U D-09 cl Other NUMBER "F,612-2- EXPIRATION DATE Ll'-1G- 2-4 <br /> DOMESTIC <br /> DOMESTIC WELL SAMPLING:U General Mineral/Coliform Bacteria(4391)O(Dibromochioropropane(4392)!_,Arsenic(4393) <br /> INTENDED USE >(Domestic/Private C Irrigation/Agricultural t I Industrial 0 Water Quality Monitoring F; Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 5(Repiacement Well t Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells [_i Soil Boring(s) ___ *of borings 1 Geotechnical a of bonngs <br /> n Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> — : New Pump 03 Pump Replacement ,I Pump Repair CJ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method )(Mud Rotary ❑Air Rotary f7 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 300 ft Excavation 7- in diameter D Open Bottom ,�r Gravel Pack/Gravel Size A,6 in diameter <br /> I Conductor Casing in diameter ! Conductor Casing Depth It <br /> Well Casing Diameter 4, in Thickness/Gauge/ASTM Sched -2&D 0 Steel p(Plastic Stainless Steel Other <br /> Grout Seal Depth 10-0 ft �i Neat Cement(94!b bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> yXBentonite(20%solids) Other <br /> Grout Placement Method '< Pumped U Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br /> i I Concrete Pedestal❑Dimensions:Width it Length it Thick in ❑ Christy Box U Stove Pipe <br /> FuMP I I Submersible[i 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 /> 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 / <br /> SIGNED C_J �- TITLE CIW DATE /0- 149-2'( <br /> c <br /> AA <br /> A <br /> T `fV11F N <br /> / <br /> DEPARTMENT USE ONLY <br /> rppl cation ACCeDiea by —' �_. Date 10 i i Area--- --. Employee ID# <br /> Grout Inspection By t' e Date n SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS S/'a Cf'. �(�T 'i��JIFCT_ �! OCI:v?D ��f�.�:�,1 t iI or � �,�P ��ssl��V, I�G^111 L^N! <br /> PE SC Received Check#/ Amount Permit/ <br /> Codas Info Remitted Date Service uest Invoice# [Nap IDS <br /> 1-1 <br /> ntirdil 370 cl L,�O <br /> EHD 43-06 8101/18 , / ' � /.� `�L ���� WELL 1'l1MP PERMIT <br />