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MPIN Wd :l B10 E 'add ;UJIl paAIa3a� <br />WELLIPUMP PERMITr <br />SAN JOA uim COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1066 EAST HAZIELTON dTON <br />AVENUE • CA 952CS - (209) 4683420 <br />INIJN-KEFUNDAULE !"tK1N11- t.ALL LV <br />6185 Mobley Rd VV <br />.log AD DREW <br />CROSS STREET <br />B a r t o l o m e i R (j APN <br />OWnER NAME <br />Eric Johnston <br />4969 West Lane <br />OWNER ADDRESS <br />CONTRACTOR <br />Drillers <br />Pur�/ <br />T�v�iTa�nce <br />T" <br />CONTRACTOR ADDRESS CBox 64 <br />)R ADDRESS <br />Csl a C89 U 0-09 U <br />)y r FUK INSF'tU I IUNJ r— r'IKGJ 1 TEAK hKVNO VAIr IZbUt:U <br />CITYIZIP Stockton <br />Q D PARCEL SUF , S 7CUD USE APPLICATIONi2 <br />PHONE <br />0Y1S'TATFJZIP Stockton, CA 95210 <br />Inc PHONE 209-897-3554 <br />clTv15TATE/ZIPL i n d e n I CA 95236 <br />PHONE <br />CnY1S-1ATFMP <br />NuluBE R 3 7 7 9 2 3 EIIPtRATON DATE 7/31/19 <br />DOMESTIC WELL SAMPLING: a General MinerallCDliform Bacteria (4399) C Dibromochloropropane (4392) = Arsenic (4393) <br />INTENDED USE X Domestic/Private O Irrigation/Agricultural C Industrial C Water Quality Monitoring O Sol Samplingicharacterizaticn <br />❑ Public Water System <br />If diferent from Owner. Wafer System Name Cantad Nem w Phore Number <br />TYPEOF WORK 0 New Well C Replacement Well C Well Meration/Modification = Other PAIK � <br />❑ Monitoring Well(s) 4 of Yds C Soil Boring(s) s orbonnps C Geolectlnical ° atbon � <br />❑ Out -Of -Service Well _ Out-Of•Service Well Renewal Cross -Connection Repair ECE <br />0 New Pump )0 Pump R.Placement D Pump Repair Raise Weil Casing <br />Drilling Method ❑ Mud Rotary C Air Rotary D Auger ❑ Cable Tool ❑ Push Point ❑ OtheT "1 11-1— <br />Proposed <br /><1Proposed Well Depth N Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Easing Depth a—�AQVIN <br />Well Casing Diameter _ in ThicknesslGaugelASTM Schad a Steel U Plastic ❑ Stainless Steel 0 Oth <br />Grout Seal Depth ft ❑ Neat Cement (94 lb WW5.10 gal water) n Sand Cement sac <br />❑ Bentonite (20%solids) 3 Other <br />Grout Placement Method ❑ Pumped D Free Fall D Other D Retardant I Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D Pump Contractor D Other <br />D Concrete Pedestal ODlmenslons: Width It Length tt Thlck in 3 Christy Bout D Stove Pipe <br />EW—P SuDmersibleD Turbine C Other HP Pump Set R Standing Water Level 11 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 13E 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 />Wo ENSAT1DN�t <br />MINI 24 H CE NOTICE SEQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95 769 <br />SIDNED - TITSorporate Secretar�y,TE <br />w <br />M <br />D <br />m <br />w <br />2018 <br />M <br />X <br />�< <br />Mo <br />M <br />Mz <br />� <br />-59 <br />tom) = <br />rn <br />PA TMENT U E N Y // <br />Application Accepted By Date Area Employee ID�If� <br />Grout Inspection By Date © SPECIAL Well Pormlt <br />Pump Inspection By A Dale U WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth it <br />COMMENTS <br />EHD43-06 BMIM6 ( r ! -7 -7 L 'NEl11PU�IP EERIER <br />X <br />M <br />0��q <br />9 � � <br />I� <br />E3a <br />9'd bL9£L996N OUB GOUeiAlnd db0:tb0 9 L E L ady <br />CC <br />EHD43-06 BMIM6 ( r ! -7 -7 L 'NEl11PU�IP EERIER <br />X <br />M <br />0��q <br />9 � � <br />I� <br />E3a <br />9'd bL9£L996N OUB GOUeiAlnd db0:tb0 9 L E L ady <br />