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" WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205- (209)468-3420 <br /> NON-REFUNDAB R IT O!QALL 209 9(553-7697 OR INSPECTIONS EXPIRES YEAR F A E ISSUED <br /> JCB AOORESS r • � CrNr7JP m <br /> Lit <br /> S�_ nn�w I D <br /> CROSS STREET v APN Z4'7124 <br /> '6 24 PARCEL SIZE '� ESQ APPucanON S I o <br /> S /1 I , /, r I l/O//3 �j m <br /> OWNER NAME "/• �O (f ly)D /ONE �(� `r W <br /> OWNER AD l� �' CITY/STAT <br /> CONTRACTOR �� 2. e { PHONE /' Z O <br /> CONTRACTOR ADDRESS i I ef I l/Al/r J D <br /> `!Y SUBCONTRACTOR -PyONE 1♦ �� !i S <br /> SUBCONTRACTOR ADO RE55 I ` ITY/STATE/ZIP I A <br /> LCENSE C-57 C-61 D-OE Other EXPIRATION <br /> DOMESTIC WELL!EPUNG: General Minerat/Coliform Bactena(4391) Dlbromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE `/Domtestir/Pnivate Irrigation/Agricultiral Industrial Water quality Monitoring Soil Sampling/Charactenzauor <br /> Public Water System <br /> it.'Ahrent fro,,. Nater System Name Contact Name or Phone Number ^ <br /> TYPE OF WORK New'Nell Replacement Well Well Alteration,.Mocif.cation Other <br /> cf bonhG: <br /> MbnitonngWellisj of wells Soil 3.,^r.rca *of borings� Geotechnical <br /> Out-Of-Service W Out-07-Serr.ce'Aell Renewal Cross-Connection Repair <br /> New Pump ump Replacement Pump Rec=,r Raise Well Casino \ <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable"dc. Dash Point Other i <br /> Proposed Well Depth ft Excavation m diac,eter Open Bottom Gravel Pack/Gravel Size in diame <br /> Conductor Casing in diameter ; Conductor Casing Depth ft <br /> Well Casing Diameter_;n Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag15-16 gai water) Sand Cement sack mix/7 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 i <br /> oncrete Pedestal Dimensions:Width_FLength ft Thick in Christy Box ;Stove Pipe <br /> Submersible Turbine Other nP Pump Set ft Standing Water Lft 9 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINA CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS , <br /> CURRENT AND ACTIVE WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT AN IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION WS. <br /> MINIMU ADVANCE NOTICE REQUIRED Fp INSPE�CCT�IONS-PLEASE CALL(209)95 <br /> SIGNED TRL_ V_ Y`Q rnotQNJ <br /> DATE l J <br /> i t <br /> I L7 <br /> SIFF <br /> 6 <br /> R0 SIN �09 <br /> C <br /> i <br /> l <br /> �1 MEN7 u44E=0 <br /> IILY <br /> Abpiicaaon Acceprec By e (-�f'`q Area Employee!Dz <br /> Gro,t Inspection By ^arc_� �� SPec1AL Well Permit <br /> Purr;Inspection By WAIVER Received <br /> Soil Bonnd inspection By Date Constructed Well Depth t <br /> :.IMMENT'S <br /> PE SC Received hec Amount ----T PemiCo s Date tJ <br /> info em ., �— — <br /> Service Re uest# Invoice III Well ID# <br /> I i <br /> I <br /> I <br /> WELL!P"IP PERNIT <br />