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911E A Md :E 8[OZ ',-Z'pc IWI j paAI;09 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNENr 1868EASTHAZELTON AVENUE -STO«Ta CA957nS. IWMIurL-in n <br />NUN -REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEC <br />Jon AOORESS 6814 N Duncan Rd /g/] 1 PARCELS Crrr/aP Linden, CA 95236 <br />C0.099 STREET c l e rn APN D i /� D USE APPLICATION 9 <br />OWNER NAME Ralph Croce <br />PHONE <br />OWNER ADDRESS 16533 E u w y 26 CITY/STATFJLPL i n d e n, CA 95236 <br />CONTRACTOR PuT`J r�/'Box <br />Drillers, Inc PHONE 209/-887-3554 <br />CONTRACTOR ADDRESS r O X 6 4 CrfY1STATE0pL i n d e n, C A 95236 <br />CONTRACTOR ADDRESS <br />NSE 'Xi C-57 ❑ C-61 0 D-09 ❑ <br />PHONE <br />Crtv/STATEIZIP <br />NumeER EXPIRAnoN <br />UUMLSTIC WELL SAMPLING; �-' General Mineral/Coliform Bacteria (4391) C Dibromochbrwrooane (43921 -1AmAnir. (4303) <br />INTENDED USE ❑ DomestcrPrivale 9 Irrigation/Agricultural C Industria; -Water Quality Monitoring ❑ Sail Sampling/Characleritabon <br />D Public Water System <br />IfdlRemMnom Owner. VhAer System Name Confab Rare or Pnoae Nurrtxr <br />.,......... . '. � rvcn ruau tllKlluMOOIRCdaOn u timer <br />O Monitoring Well(s) # of weiis r] Soil Boring(s) o w Lodrgs C Geotechnical 0 at rer" <br />0 Out -Cf -Service Well O Out -Of -Service Well Renewal D Cress -Connection Repair <br />Ci New Pump C Pump Replacement /Pump Repair _1 Raise Well Canine <br />',Orllling Method O Mad Rotary ❑ Ah Rotary D Auger D Cable Tod O Push Pmt D Other <br />Proposed Well Depth_ft Fxcavatfonin dtameteT D Open Bottom C Gravel Padic/Gravel Size in diameter <br />❑ COrlduClor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in TNcknesslGauge/ASTM Sched ❑ Steel 0 Plastic D Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neal Cement (94/b W9'S10gal water) 7 Sand Cement sack rrdx/7 gal water <br />D Bentonite (20% solids) D Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other C Retardant I Accelerator (name) <br />PEDESTAL Installed By 5 Driller 7 Pump Contractor ❑ her <br />D Concrete Pedestal CDimensions: Width ft Lerath n Thirk <br />7'UMP ❑ Submersitrle Tur4ine 7 Other HP - 7,r- <br />2— PUMP Sef � —ft Standing Water Level R <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THS 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 />WORKEflZ7CU9PEAjSATION LAWS. <br />24 HO AN NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />T,„ orporate SecretarlyATE 2/23/18 <br />$DLEARTMENT USE N Y <br />Application Accepted By Dale Area Employee IDN <br />Grout Inspection By n DateWCsq <br />E IALWll PermitPimp Inspection By Date C WArVER Received <br />Soil Boring I specho n 9y Date ---�� Cons eted Well Depth <br />COMMENTS \.'e L o f vvI n t r no, �-I 7 � e I_ . i <br />�my <br />ip <br />0 <br />Ion <br />N <br />�FY °WEn►r <br />DIVED <br />FE8 2 6 2018 <br />►VVIjRO/V COUNTY <br />EN <br />LTH OE gRrMENT <br />• <br />%lo1//+'�ti'`b��rIL�AIIi►'�/,iT�lii�Y.#�T`�!� <br />••r r1 • • <br />END434E amwE <br />WELL rPUMP Pl;RNI <br />6'd VZ9U9960Z out SaaIIuQ aoueiAind <br />