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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468.3420 <br /> NON-REFUNDABLE PERNT ` l\ www.s pov.o lehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V`/�3t (0 7 7 N 1 ���{ S G�` GTr/Lp A—C C` <br /> CROSS STREET W0 LI� S L''1 D APN O V�� I�l� OO PAACEL SIZE L IANO USE APPLICATION <br /> W cl A <br /> DYRIEH NAME C'��' \ PHONE 1O <br /> �OWNER ADDRESS 5 C/TYISTATEJIIP / 't <br /> CONTRACTOR ���(-t�/ /l J/ t ^'A PHONE ��-'(� 4' I — -7 /�7 LI i <br /> CONTRACTOR ADDRESS P 0 1�C /� Cm'ISTATE/ZIP <br /> SUGCONTRACTORICONEULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CrrYfSTATON <br /> EfhP �1 <br /> LICENSE )4.C-57 G ')'19393 61 D-09 Other NUMMR ExPwATIDATE /-7-3 1 <br /> 1BILUNG PARTY: --OWNER .CONTRACTOR SUBCONTRACTOR/CONSULTANT +� <br /> DOMESTIC WELL SAMPLING:,(General MineraUColiforrn Bacteria(4391)x DibrornDchloropropene(4392)".Arsenic(4393) <br /> INTENDED USE W6omeSbcJPnvate Imgation7AoCultural Industrial Water Quasy Monitoring Soil Sampling/Charectenzation ZC <br /> iJ Public Water System <br /> It eifl+m eom Owner Water System N.— Contact N.—a Phone Nwrber <br /> TYPE Or WORK New Wel Replacement Wag O Well Afteration/ModifiCarion .Other C 1 <br /> .;Monitoring Wel(s) i of vets 'u Sal Borings) a o7 h0""o`' Geotechnical Nor Twerps SAN J <br /> D Out-01-Service Well 11 Orn-Of-Service Well Renewal Cross-Connection Repair h yt'A(�1 o(J/h 01j <br /> New Pump_ Pump Replacement D Pump Repair Raise Wel Casing lvM <br /> WELL CONSTRUCTION �'p,�RAj, <br /> Drilling Method-Mud Rotary Air Rotary `Auger Cable Tool .Push Point Other rNr. <br /> Proposed Well Depth d 4 5 ft Excavation,�_in diameter I::Open Bottom 7k Gravel Pack/Gravel Size i/4- In diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Q in Thicknesa/Gauge/ASTM Sched Steel Plastic .Stainless Steel Other <br /> Grout Seel Depth 10 C R Neat Cement 1'94 lb bag/5-10 gal water) jL Sand Cement 10"j sack mixA gel water <br /> "Bentonite(20%SOW is Other <br /> Grout Placement Method Pumped D Free Fad I Other Retardant/Accelerator(mune) <br /> sT L installed By'-A Driller [::Puntp Contractor Other <br /> X Concrete Pedestal(:'Dimensions:Width:::5_R Length— ft Thick in :::Christy Box - Stove Pipe <br /> PUMP }[,Submersiblefl Turbine .�Other HP Pump Set 1 tt Standing Water Level -tt <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953 7697 <br /> SIGNED TITLE \I r C e ',d e A'f DATE I ` <br /> U� <br /> / I S <br /> J <br /> E <br /> O <br /> DEPARTMENT U5 ONLY <br /> _ l�y R <br /> Application Accepted By Dale 6 �I d 1 Area y 1 Employee IDN_ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By a Date WAIVER Received <br /> Sal Boring Insp"By Date Constructed Well Depth R <br /> COMMENTS I`pt-J <br /> PE SC Received Amount Permit] invoice N Wel IDN <br /> Codea Mfo Remitted nice Re uaatN <br /> opo sit <br /> (5 <br /> ski ISO i Mfr <br /> ,13 1 <br /> PH043-Oa all tY019 WELL rPUMP PERMii <br />