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WELL/PUMP PERMIT <br />SAN JOAQUIN Couli ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4"-U20 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />LG—E <br />ApOREss ��y'}('-©0 '✓ 1 APN03q —1It' — I2— PARCEL Slim_LetaUSEAPPuuTIOlR NAME , Uri t I Q1� G hOt^ 1PHitdi 331 --722q <br />cA q,72 -,Io <br />!CowrRACTOR <br />S2 o <br />!CONTRACTOR !" rl p �7! (� L L PHONE <br />CONTRACTORADDREsa2316__`P,Iv __• �J�{i.. 3�> Cf}Y/sTA7lrap <br />SUBCONTRACTOR _ - PHONE <br />SUBCONTRACTOR ADDREM <br />C-57 D "1 D-09 <br />NUMBER <br />DoYEznc WELL SAMPLING: C General MinsraUColiform Bacteria (4391) ; I Dibromochloropropone (4392) Arsenic (4393) <br />INTENDED USE ' DomesEdPrivate -1 InigatloNAgricultrral D Industrial r Water Quality Monitonng ;k5O:I bamprngrCnaractenzatwn <br />C Public Water System <br />II dieser[ tom Ownr. Wrier sitinsm Nem" Correct Narro s Phw Number <br />TYPE OF Wows D New Well �- Replacement Well <br />n Monitoring We'I(s)_____ # of wets <br />-. Court-Of-Servioe Well <br />New Pumo I Pumo Replacement <br />(I Well Alteration/Modification D Other <br />)CSoil Bonng(s) _ 7-_ #deere,pe O Geotechnical <br />Out-OfServ:ce Well Wnewal D Cross -Connection Repair <br />Pumo Raoair Ra',se Wea Casino <br />e of boring. <br />Drilling Method I Mud Rotary 7 Air Rotary - Auger n Cable Tool )(Push POW 17: Other_.__,___,_ <br />Proposed Well Depth. 50 ft Excavation Z in diameter O Opan Bottom 5 Gravel PacVGravel Size lndhwn*W <br />.� Conductor Casing _--in dameter l Conductor Casing Depth --ft <br />Well Casing Diameter -i-in Thleknes&`Gaage/ASTM Sched _ n Steel D Plastic :, Stainless Steel D Omer <br />Grout Seal Depth._ rG_ft >(Neat Cement (94 lb bag5.10 gal water) Sand Cement_ . sack mixr7 gal water <br />n Bentonite (20% solids) :1 Other <br />Grout Placement Method D Pumped ,)(Free Fall C Other .1 Retardant I Accelerator (name) <br />Fft—NWTAL Installed By C Driller D Pump Contractor D Other <br />n Concrete Pedestal UDlmenslons: Width It Length ft Thick _ in fi Christy Box 11 Stow PIPs <br />Pump + ^ Submers'ible:I Turbine a Other HP Pump Set ft Standing Water Level ft <br />IHEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />J OAQUIN COUNTY O DINANCES, STAfck LAWS, AND RULES AND REGULATIONS. r ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACT WITH THE C�fORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. // i <br />NOTICE <br />SIGNED <br />E/PjARTMENT�yy1-�SCf O LY <br />App' cabon A—pted ByA✓ Data <br />✓ 'J <br />Grout Inspection By Date <br />Pump Inspection By q� <br />Soil Bo -ng Inspection By <br />COMMENTS <br />Data <br />Date <br />CALL (209) 953-7697 Gr <br />Ma1. A" t Employee IDP <br />❑ SPECIAL Well Permit <br />WAVER Received <br />Constructed Well Depth _ <br />IM43 8 reWsdenYte WEiL PUMP PERMIT <br />