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May 10 19,08:07a P. <br /> WELLIPUMP PERMIT <br /> SA AOUIN COUNTY ENVIRDNNENTAL HEALTH DEPARTME tT 166a EAST 14AZELTON AVENUE-STOCKTON CA 952DB-(269)468-3420 <br /> NON-REFUNDABLE PERWT CALL'209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED m <br /> CITY(2:lp (/ t7 m <br /> JOB ADDRESS D Z _ - D <br /> Qillf7 X1.0• 1PARCEL StLv L1NOI35EAPPIJCATION+� a <br /> CROSS STREET A2, ,/D}lG (�,�=N.��_�_]�APN O 1 D <br /> OWNER NAME _( /0.eIl,[�'�•.,•' ' `?� PPHONEa'9� <br /> �r Dr r'�L�JC J�(L CITYISTATEZP v� <br /> OVA(ER ADDRESS f��j - <br /> CONTRA=R - —r !/G/</ll ��J.J--.rv�=ir-' M PHONE <br /> 2/�D <br /> CONTRACTOR ADDRESS //� IY� CI YISTATE.ZIP� <br /> - <br /> SUBCONTRACTOR !/!r� p�'I�-- ---6i- -i f� PHONE <br /> C IT VIST0.TPJL P <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE. 0 G-09 7Other <br /> NUMBER �P�O �/� ExP1RAT1,0N OATS <br /> DOMESTIC WJ1 SAMPLING:J General iAineral/Coliform 3acleria(4391)0 CiSromochloropropane(4392)0 Arsenlc(4393) <br /> IVTENDED USE D Domes Jc Pm ate rrig atiordAg rlcultural 0 Industrial C Water Quality Mcnitoring 0 Soil Samp'nglCharacterizabon <br /> 0 PLbfic Water S tem ConixJ Name or=hme Number <br /> I,,r''driere t I,=Owner Wale/Eystem Hary <br /> TYPE OF WORK eN We It D Replacement Well O SVell Alterati:ntIVIod fcalion C Other sdoainos <br /> - Y of wets 0 Soil 80'""'9WMd oaings 0 Geotechnical <br /> D Monioring Well(,) <br /> O Out-O,'-Service Well U Cut-Cl-ServicB Wel Renewal 0 Cross-Conaeclion Repair <br /> k'leW Pump 0 Pump Heplecenent ❑Pam Re air G Raise Well Cas.n <br /> WELL CONSTRU.TON <br /> Drilling Method G Mud Rotary O.Air Rotary D Auger 0 Cable To^l 'U Push Po,W G Other <br /> Proposed Well Depth�_R Excavation,—In diameter U open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in ciameter i COndL'cter Casing Depth ft <br /> Well Casing Diameter-��niin�ThicknesslGaugelASTM Schad 4J X-'Q 6 Steel )1411 lic 7 Stain!ess_S1ael 0 Other <br /> Grout Seal Depth— _R 0 Neat Cement(94 to bag7ST0 gar , <br /> wafer) '-1 Ind Cerrent •:• - s5ck mizr7 gal water <br /> ,,V$ento-iite(20%solids) 0 Other / <br /> Grout Placement Method umpad 0 Free Fall 0 Other G Retardant/Accelerator(name) <br /> PEDES-AL Instilled By ❑Driller C Pump ConVgct it O. o1heT - in 0 Chris Boa C Stove Pipe <br /> D Concrete Pedestal ODlmensions:Width n Length _R Thick t1l <br /> pUyC ubmersibleD Turbine 0 Other HP_Z,5 Pump Set R Standing Water Level _ ^ft <br /> HEREBY CERTIFY THAT ! 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 ACTNE WITH THE CALIFORNIA CCNTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIr�.!ZYLf <br /> I'/j/y{'.f' VANC}EJ�N(OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)/5 -7697 <br /> TITLE �.yJ:7�/� _ GAT <br /> S:GNE o <br /> _ <br /> E N T U S E O N L Y <br /> , �z�/G/ <br /> Application Accepted By'7fr =``/ Gate -s�L Area i Employee D# L <br /> Cate Q PECIAL Well.Permit I <br /> Grout inspection 4y <br /> Pump InsoeUUion By Date i I WANER Received I <br /> SDA Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck Amount Permit/ Invoice Well 1134 <br /> .Codas I o B <br /> �t`a.I emitted Date Service Request 0 <br /> TJ"7 � wEGLIyfLP tJr.U+PERMi <br /> .HD 93-"6 &01116 <br />