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Wti "N AVLS : OI 2[H 'Ll 'iris ;WIl paAI ; <br /> WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA7EI.TON AVENUE-STOC7(TON CA 95205-(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS clTwze S t o c k t o n CA 9 5 2 1 5 m <br /> n <br /> CROSS STREETAI pzne Rd APN 01- I.ELSIZf LAND USE ApPucanoN# A <br /> OWNER NAME PHO,7,0 9—4 01—5 213 � <br /> OWNER ADDRESS P .0 . Box 1509 cnylsTATFmFL i n d e n CA 95236 <br /> CONTRACTOR PilAnce flrillers , Inc PHO..77NE 209-887-3554 <br /> CONTRACTOR ADDRESS 'PO Box 64 CIT VISTATFIZIPL i n d e n , CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SuscowPACTOR ADDRESS CITYISTATPJZIP <br /> LICENSE C-57 U C-61 130-09 0 other NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/31 /19 <br /> DOMEsnc WELL SAMPUNG:C General ivineralColiform Bacteria(4391)c.Dibromochloropropane(4392)-j Arsenic(4393) <br /> INTENOED USE ❑DomesbdPnvate _ Imgation/Agricultural D Industrial C Water Quality Monitoring 0 Soil SamplinglCharacleriza4on <br /> D Public We1er Sys ern <br /> Irtlleeren[rram Owner. Vdalar SyYem Name Conlad Name aPnone Number <br /> TYPE OF WORK 0 NCVI Well C Replacement Well D Well AlterationfModication D Other <br /> 0 Monitoring Well(s) #of Wells D Sat Boting(s) a a1 borings 0 Geolechnical n orbonngs <br /> U Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pump Pump Replacement C Pump Repair 0 Rase Well Casin <br /> WELL CONSTRUCTION <br /> Drilling kilethod 0 Mud Rotary G Air Rotary ❑Auger 7 Cable Tool ❑Push Point -1 Other <br /> Proposed Well Depth ft Excavation in diameter =Open Bottom D Gravel Pack7Gravel Size in diameter ' <br /> 0 Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in TlucknesslGaugerASTM Sched = Steel O Plastic ❑Slainless Steel 0 Other - <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bagy5-10 gal wafer] ❑Sand Cement sack mrx17 gal water <br /> 0 Bentonite(20%solids) J Other <br /> Grout Pkacement Method U Pumped 0 Free Fall 0 Other =RetardantlAocelerator(name) <br /> PEDESTAL Installed By D Driller 7 Pump Contactor U Other <br /> O Concrete Pedestal 013imensions:VVid1h it Length ft Thick in C Christy Box 0 Stove Pipe <br /> PUMP ❑S_ubmersible Turbine .7 Other rip Pump Set It Standing Water Level h <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS--COMPENSATION LAWS. <br /> MINIM kF 24 H A ANCE NOTICE REQUIRED(FOR INSPECTIONS-PLEASE CALL(209) S3-7697 <br /> c TITh'o r p o r a t e S e c r e t a r SATE <br /> MEN <br /> T <br /> II FIVFo . <br /> 8 ?018 <br /> jW <br /> co <br /> N ILP ENTulvey <br /> RTMENT <br /> I <br /> 1 <br /> EPA TMEN_W/E77/ <br /> U E O <br /> Application Accepted By ale 7 �I Area_�ft Employee rD* b <br /> Grout Inspection By Date ❑1 STPECIAL WeII Permit <br /> Pump Inspection By 14AAA 7JRM Date "Z" i7 WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Perm itl Invoice# Well 100 <br /> C es Into B h Remitted ice R nest# <br /> '-L <br /> EHD 43rIfi e/J Vtfi <br /> 821'1YT / WLrPUMPPERMrT <br /> /KJ_ EL <br /> £'d VLS£L9960Z out SJ811!.lQ aoueiA.lnd eLZ:0L 96 LL deS <br />