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�n 07 19, 10:35a p.1 <br /> Jin, 1- 2E}I;' S: 170 Pio. 4548 °. 1 <br /> 0% <br /> ■ <br /> WELLIPUMP PERMIT <br /> SAN JDADUIN COUNTY EHv1RON1JEN7AL HeAL7H DEPARTMENT 1866 EAST 14AZELION AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMrr CALL 209 853-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> Joe ADoRess � 5� �.C( Clamp �i S, D <br /> C.Q0.S5 STREET ♦��/ L > f�QAPN 0 ✓ PARCEL SIZE LAND USE APPLICATION it A <br /> OWNER NAM is . o� (�hl y <br /> O'wNERADDREaa CITYJSTATEIZIP �3lPrd�/f/ <br /> CONTRACTOR , '/D PHONE <br /> CON TRACTOR ADD17E55 71Grt�I�. CITYISTATEIZIP �/'� a` <br /> SUBCONTRACTOR �- PHONE �1 <br /> SV9CONTRACTOR ACORESS CiIiTTYJSTArFJZI <br /> LICENSE S7 V-61 0 D-CS C Other NUmsER !6 ExRRATON DATE J <br /> DOMESTIC WELL SAMPLING:E General Mine al/Coliform Bacteria(4391)D Oibtomochloropropane(4392)C Arsenic(4393) <br /> INTENDEOIJSE Uomast,vPriva!e D Irnga!an/Aariculrurel 0 tndus'.nat 0 Water Quality rAcri t eng O SDA SamplinglCharacledzpVon <br /> D Public Water System <br /> if Wye-ell'".Owner, Ylaler Er7tett Name Q",An Name ar Phonemy Tleer <br /> TYPE OF WORK 0 New Well 0 Replacernenl'VVell 7 VVellAllerallonAmodilCatlon 7 Other <br /> ❑Monitoring wellts) #of WeIIs 0 Soil Boring($) 91 v1 baring ❑GeoteChnlCal for Bodnar <br /> ❑Out-Of-Sery ce'Nall 0 Out-Or-Service Well Renewal J Cross-Corinedion Repair <br /> D New Purrp vmp Re lace'nant 0 Pirrp Repair 0 Raise Well Casio <br /> WELL CONRTRVCTIOr1 P'/YiWEly <br /> Drilling Method 7 Mud Rotary 0 Air Rotary 3 Auger ❑Caole Tool 0 Pvsh Point 13 Other /�(/�1 <br /> Proposed Warl Depth R Excavation In diameter 0 Open Bottom ❑Gavel Pack Gravel Size u�Iter <br /> 0 Conductor Car-Ing in diarneter / Conductor Casing Depth fl OCT L q g 201 <br /> Well Casing Diameter_in ThicknesSIGeugelASTIA Schell 0 Steel 0 Plastic O Stalnless Steel D Other d 8 <br /> Grout Seal Depth ft D Neat Cemanl(941b begVS-10 ge0 wa tv4 0 Send Cement JO ppl .lyater <br /> 0 Senicrike(20%solieB) 0 OtherHFa�T+RID ENTAL <br /> Grout Placement Method O Pumped 0 Free Fall 0 Olher 0 Retardant I Accelerator(name) TMENT <br /> _PEDESTAL Irstarled By 0 DrIIIK D lump Contractor C 011'er <br /> C Concre>gPedestal❑Dimensions:Width tt Langlh ftThitic in ❑Christy Box 0 Stove Pipe <br /> PLMPobnnerslble0 Turbine D Other HP Pump Sel n Slandlnp Water Level fl <br /> I HEREBY CE TIFY THAT i HAVE PREPARED THIS APPLICATION AND T.-IAT THE WORT(WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGU:-ATIONS I ALAO CER7IFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WfrH THE CALIFCRNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C PENSATION LAW- <br /> MI 9 UR NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209))85 -7697 p <br /> SIGNED /' TLE �ieiCi/l�l DA`ry I ! <br /> i <br /> c <br /> I ` _ <br /> 1 I <br /> P 1 <br /> I I <br /> E P A R T M E N TUJ S/7E ON/�L1/�Y <br /> Application Accepted By Date,� / "JJ�t,,d/ { A:ea J W Employee ID,O_�L <br /> Growl Inspec70n By Dat_= O PECIAL well Permit <br /> PurrP Inspection By Fr�N�_1iL0t„�r,A.bM Data l0 n� t b 0 WAIVER Recelved <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Ch ckU! Amount Date Perm' InvolcoWpJI IDA <br /> Codes Info Remitted 5 ce Re west or <br /> i0PMftA4j CQW73 <br /> `­'Received T me Jan, 7, 2019 9 : 37AM No, 4550 1WLL)Pi,,WPERMIT <br />