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WELL/PUMP PERMIT <br /> SAN JOAO AN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �"Sy �, R <br /> Joe AODRI-ss 1 6 C1n/21PY�,A� /a CI S -2��y � <br /> -� ��� `� <br /> CROSS$TI EE7 tV\1Y�[t_YY\ �G"I-Y\�/`-\r.L%�PN 4%-O�{.y-Z� PARCEL SIZE"(14,�C�LAND U EIPPLICA"ON# v <br /> OWNER NA JE } T'f\` � p <br /> {7 �a --e-�. <br /> PHONE � N <br /> OWNER AD MESS l �,S (�` \ \`C L,- CITY/STATEI 1P�♦CA—Ti CA (-t C�)3(:)y <br /> CONTRACT)R I Y�r�+�\C� L..r(�.J��S�Y� 'jT�'t\i'l� PHONE Z��`-C7�SLA <br /> CONTRACT 7R ADDRESS L`5S !V , M�`I-tY � Y CITYISTATE0P_-T I—C-TI `A `\5��� <br /> SUBCONTRICTOR PHONE <br /> SUBCONTR ACTOR ADDRESS CITYISTTAATEIIIP�'�y [i1 <br /> LICENSE i C-57 C.C-61 L!D-09 Other NUMBER �✓2-- l/SEXPIRATION DATE Q 1 <br /> DOMESTIC WELL SAMPLING:1.';General Mineral/Coliform Bacteria(4391).:!Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED L SE DomestirJPrivate ��- InigaGon/Agricultural 1 Industrial _!Water Duality Monitoring Cl Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Warm System Name Cwnacr Name or Phone Number <br /> TYPE OF W MK -:New Wel Replacement Well a Well Alteration/Modification U Other <br /> MonitoringWell(s) #Dfwells CSoilBodri #ofhonn95 Geotechnical Aorbodngs <br /> Ou[-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> �New Pump 1,Pump Replacement U Pump Repair _ ...I Raise Wel Casing <br /> WELL CONS TRuc nON -- <br /> Drilling Me frod 'J Mud Rotary -:Air Rotary i Auger i I Cable Tool J Push Point i Other <br /> Proposed Nell Depth ft Excavation in diameter _I Open Bottom Gravel PacklGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched CI Steel ❑Plastic Stainless Steel Other <br /> Grout'eat Depth ft —Neat Cement(94 Ib bagl5-10 gal water) n Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) G Other <br /> GroutPlacment Method ;:Pumped is Free Fall 1:Other !?Retardant/Accelerator(name) <br /> PEDI ESTAL 1 tailed By Driller - Pump Contractor J Other <br /> Concrete Pedestal.._Dimensions:Width ft Length ft Thick in ❑Christy Box 11 Stove Pipe <br /> PUMP Submersible:Turbine Other HP Pump Set '1 O It Standing Water Level I l7 ft <br /> I ,CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN r:OUNTY 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 C ENSATION LA�AA <br /> S. <br /> rlP PA 48 £)Lr� TICE REQUIRED FOR PLEASE CALL(209)953-7697 <br /> STONED_ r TITLE DATE <br /> J,/-� �C�J�(/ — Y <br /> -e <br /> pqy4f, <br /> a4Fc�eeV�T <br /> A% <br /> JON 2419 <br /> Fivl,,Ro(/jH Co <br /> E`1CTyD pgRNT t <br /> MHT <br /> L LFI <br /> H 4 4 -- --------- <br /> ----------- ------ --------- <br /> l)8 ME <br /> NT E O Y <br /> Application Accepted By ate t Area;i Employee ID#� <br /> Gro A Inspection By Date L; PECIAL WBII Permit <br /> Pun p Inspection By _ N �liC'y��!1,\�� Date L\ WAIVER Received <br /> Soil Bonr g Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Permit/ <br /> o s Info Cash Remitted Date Service Re es Invoice# Well ID# <br /> 1 <br /> EHD 43-06 revise 14!14/18 <br /> 18183 WELL(PUMP PERMIT <br /> �r 8q� <br />