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WEI-LiPU P PERMIT <br /> i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46&3420 <br /> NON-REFUN061N,,E PERMIT CALL <br /> (209 953-7!n7 F R INSPECTIONS EXPIRE YEAR O DATE ISSUED <br /> ,t <br /> JOB ADDRESS 1 ri S r / t/t/s/ CITYMPLILI? T <br /> q � D <br /> CROSS STREETZIAIAfAPN ? `PARCEL SIZE,,LAND USFJ1pD 51ON v <br /> oV SLJ.- m <br /> OWNER NAME G /� UU /I/t 7/t �v/1 PJ$ONE // m <br /> OWNER ADORES$ ` `4 I , ` E l V-1 El,/ 1� CITY STA IP CC `+ t� ` <br /> CONTRACTOR Z + S 14,1PHp // ` v <br /> CONTRACTOR ADORAES`5 le t T GITY/STAT L C ! <br /> SUBCONTRACTOR l v A PHO'/N`EI I� <br /> SUBCONTRACTOR ADD RES$ VV ITY/STATEIZIP / V �Cr• <br /> LICENSE 0-57 -7 C-61 D-09 Othe - NUMBER �O E)mR.oN DATE <br /> C^ <br /> IZ-1 3 1 PLO <br /> DOMESTIC WELLL�UAPUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDE— o USE " Oomestic/Private Imgation/Agnculural Industrial Water Quality Monitoring Soil SamplinglCharacterization <br /> Public Water System ! e <br /> It.-afferent from Owner. 'Nater System Name Contact Name or Phone Number I <br /> TYPE OF WORK New Well Replacement Well Well Alterabon,lvlooifcat,on Other I C� <br /> o' <br /> Monitoring Well(s) #of wells Soil Bcringis I tt of bongs Geotechnical # bongs i <br /> Out-Of-Service W Out-Of-Service`Neil Renewal Cross-Connection Repair <br /> New?um Raise Well Casing <br /> _ <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger CaDle Tori Push Point Other <br /> Proposed Well Depth It Excavation m ciarre:er Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter i Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal watery Sand Cement sack mixf7 gal water <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 /> oncrete Pedestal Dimensions:Width It Len In 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 /> UVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 7697 <br /> SIGNED _ TITLE 14 FA A/I0 4_ DATE 111LA jig <br /> ! I i --r <br /> i <br /> i i i i i i <br /> I 11i Lw4F 4Nto A <br /> 13 <br /> oA ®19 <br /> Q <br /> T� M CpUN <br /> RON <br /> pEpgR�� 7Y <br /> A -M ENT' U EOJJ LY <br /> Application Accepted By - - — Cate�y6Area Employee ID# <br /> Grout Inspection By Date PeaAL WeII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sal Bonn d I on By Date Constructed Well Depth ft <br /> :D%'kfENTS <br /> PE SC Received C Amount Permit/ <br /> C es Info B Cash Flemitted i Date Service Re uest# Invoice# Well ID# <br /> 031111 WN uajvTj� <br /> I <br /> I I <br /> ._r - WELOPUMPPERMIT <br />