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i, ([ <br /> WELL/PUMP PERMIT II <br /> SAN JOAQUIN COUNTY ENvIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(2U9)46I2-D <br /> .42W L-1 L� <br /> l <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS lJ 01/ fit/ -JT CRYRIP �/_, � •5-7,C, • y <br /> CROSS STREET �L �y k` e- APN J1 f1—✓es RCELSIZE � D <br /> 12JELAND USE APPLICAATIoN ` o <br /> OWNER NAME r�f CL C. 1 1'1 �,�� PHONE S-/6•^73,/` t 3 iZL HN <br /> OWNER ADDRESS (J �) �/ �t i r) -C[L� - CITYISTATE/ZIP <br /> C•' <br /> CONTRACTOR N �I rl I�L I///1'1/ JrP/H'OJ�N�TE <br /> CONTRACTOR ADDRESS/' t-1 C/ y/? C ��{'• CITY/STATEIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -C-57 CC-61 -D-09 C Other NUMBER EXPHtAnON DATE <br /> DOMESTIC WELL SAMP 22: General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE1111.12,6mesticfPrivate _ Inngation/Agricultural - Industrial -Water Quality Monitoring Soil Sampling/Characterization , <br /> D Public Water System <br /> If dilfcrc°x 4-0— Wale,System Name Conlau Name or Ph—Nlmiher <br /> TYPE OF WORK G New Well _Replacement Well _Well AlteraticruModficabon _Other - <br /> ❑Monitoring Well(s) _#of wells Soil Bonng(s) 9 of bortVs Geotechnical z <br /> O Out-Of-Service Well -Out-Of-Service Well Renewal -Cross-Connection Repair <br /> !!1Qe`w Pump Pump Replacement :=Pump Repair L Raise Well Casing -` <br /> WELL CONSTRUCTION \ <br /> Drilling Method Mud Rotary Air Rotary Auger _ Cable Tool - Push Point - Other <br /> Proposed Well Depth it Excavation in diameter -Open Bottom -Gravel Pack/Gravel Size in diamel6 <br /> Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in ThidtnesslGauge/ASTM Sched -Steel -Plastic Stainless Sleet -Other 00 <br /> Grout Seat Depth ft C Neal Cement(94 1b bag/5-10 gal wafer) -Sand Cement sack mixl7 gal wale Q <br /> r <br /> - Bentonite(20%solids) Other <br /> Grout Placement Method -Pumped 7.Free Fall -Other :_-Retardant/Accelerator(name) J <br /> PEDESTAL Installed By -Driller -Pump Contractor - Other <br /> Concrete Pedestal C.Dimensions:Width It Length ft Thick in -Christy Box -Stove Pipe <br /> PUMP _Submersible-Turbine - Other HP Pump Set ft Standing Water Level ft <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 /> IMUM 8 OUR ADVANCE NOTICE REQUIRED FOR INSPECTNS -PLEASE CALL(209)953-7697 <br /> S.N. Tr1LE Or-L'i' ri l DATE [ -/7 <br /> C�����' <br /> ?p19 <br /> VAN C <br /> C, P, OU <br /> NAY <br /> ,/ NT <br /> 2R. R.T T U E O LY n <br /> Appliczifion Accepted By U 2- Area Employee ID# <br /> Grout Inspection By ^U `, `1 Date - PECIAL Well Permit <br /> Pump Inspection By A ,w 1J Date G WAIVER Received <br /> ---r r <br /> Soil Boring Inspection By Date_ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Date PertnHl Invoice# Well ID# <br /> Cods Info Cash Remitted Service Re uest# <br /> his i <br /> END 4306 wised VIVI8 .7 9J- / y�? L WELL(PUMP PERMIT <br />