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• , <br />r <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -KEFUNDAB L PERMIT <br />1 YE FROM ATE D <br />GALL Z09 953-7697 FOR INSPECTIONS r I <br />JOB ADDRESS <br />CROSS STREET l NTra� <br />OWNER NAME e r)tW--/t <br />r/Ey�/XJPJIRES <br />u CITY/Zip "— S G T5 7&T <br />A7PN /t� ���j�-{ �� JP�AR L l2dd' V3LAND IJ A/P/'pLICATIIOON # <br />1, Y r L-�� I HM <br />7(� � -/ <br />OWNER ADORES $ _r <br />CONTRACTOR <br />��Jj► <br />/ <br />�"•" <br />IV <br />//fit �/ '/1/► 14� <br />CITY/ ATOP lA� VI 15 �l/ <br />F�-1. I P ON' f�v <br />{��I1L�'}/{�'_� <br />r • " ' r / { <br />CONTRACTOR ADDRESS <br />/Vt; <br />L <br />IVIV <br />CITY/STATE `-'l' <br />SUBCONTRACTOR <br />PHOON <br />• <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 <br />tet) CITY/STATE/ZIP— • - <br />� NU BER' lK� EXPIRATION DATE <br />C-61 D -D9 <br />0[he <br />DOMESTIC WELL AMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 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 Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical ft of borings <br />Out -Of -Service Well t -Of -Service Well Renewal Cross -Connection Repair <br />_ New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) it <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />M El <br />,Date <br />Date <br />Date <br />Date <br />3 <br />./41N -'cl <br />�ogQ�BH 4 ?918 <br />'�i <br />1•y � �N <br />R <br />Area r/ Employee ID# _1,4qW( MFNT <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-06 8101116 <br />WELL /PUMP PERMIT <br />tTr1 /, r�r �• � <br />• - iii <br />_�� <br />• <br />ANOM■!■■■!■eL'!.i]■■■■N■■MM!!i■■■■■■■■■■■■■■■■ <br />ilii■■■■■■■■■ !■!!!■■■■■lffig"MM7■■■■■■■■■■■■■■■■ <br />amom■INNEM■li�AId■■ <br />Lill'iliiiil.Ju:�i1■!11!■■■1■■!!!!�/I!■■!■I!■■■■■■■■■■■■■■■! <br />• <br />16311 iupLIR1nJ■\'■■!Ir_RiS■■IL FAIT- ■IiP7,M■■■■■■■■■■■■■■■■■ <br />■■■SLAIL Ti■ M 000!■ITRAIl09.�■L,■!■■■■■■■■■■■■■■■ <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />M El <br />,Date <br />Date <br />Date <br />Date <br />3 <br />./41N -'cl <br />�ogQ�BH 4 ?918 <br />'�i <br />1•y � �N <br />R <br />Area r/ Employee ID# _1,4qW( MFNT <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-06 8101116 <br />WELL /PUMP PERMIT <br />