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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDA E R T CALL 09 953-76 7 FOR INSPECTION EX RES 1 YEAE,FRO"6a ISSUED <br /> y <br /> Joe AzoaEss Crry,7J `^ m <br /> CROSS STREET APN � ARCEL SIZE LAND IjSfSAePLI�ATION# a <br /> AleVV Q 1`I/ oo — m <br /> N m <br /> OWNER NAME (//�.� ' <br /> OWNER ADORE y /t' /y-i Ica CITU STATE/ZIP -• v <br /> CONTRACTOR �t/r • • 1 • / " P ONE <br /> CONTRACTOR ADCj <br /> ORES O Y CITY/STA I -w✓ _ `' <br /> (SUBCONTRACTOR WE ` <br /> SUBCONTRACTOR ADDRESSISTA/TJE/711' W <br /> LICENSF C-57 C-61 D-09 Other NUMBER 1vi In Y T dXPIRATION DATE <br /> t� <br /> DOMESTIC WELLS LING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) Q) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System JILN <br /> If different from Own Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well V Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(S) R of borings Geotechnical x of borings <br /> VNut-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew 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 It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water 1 <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> C mete Pedestal Dimensions:Width ft Len th ft Thi in Christy Box St ve Pip ^ <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level it r <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 ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKE PENSATION L WS. <br /> I MUM 24 H U ADV CE NOTICE REQUIRED F INSPECTIONS-PLEASE CALL(20�)74 7 9 A , <br /> SIGNED RLE4 104 DATE C <br /> Y <br /> �EovE <br /> 01 P: TMENT U E N L Y <br /> N 9 2o1�pplication Accepted By ate Area Employee ID#� <br /> rout Inspection By Date PECIAL well Permit <br /> r GQVNNNN�ump Inspection By Date WAIVER Received <br /> ��JO���MENing Inspection By Date_ Constructed Well Depth —__ft <br /> SNS��p�NTS - <br /> N�� <br /> PE SC Received a Amount Date Permit/ Invoice# Well ID# <br /> �soclq§ Info By- ---C7Sh Remitted ftlmltenuest$ <br /> EHD 43-06 6/01116 WELL(PUMP PERMIT <br />