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` ELL/PUMr PERMIT <br /> ,SAN.JOAQUIN COUNTY ENVIRON.VENTAL TN EPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95205•(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 20 19 3-7697 FOR INSPEC O EXPIRES 1 YE �ROM ATF SUED <br /> / UY) <br /> -;,-,a ADDRESS %jom m <br /> ,Q r <br /> CROSS STREET I � APN r q 3 I��4�' PARCEL SIZE 0•T't Lwp USE APPLICATDn a: I o° <br /> m <br /> OWNER NAME 1 • '10 /�PHON rwo <br /> OWNER ADDRE //'' 1 ,�' q ••• �G <br /> CONTRACTOR It/J/�V6 I-evil P/ L P{�/Jq�N) '` V <br /> IT)91 <br /> CONTRACTOR ADDRESS V ✓" It CITY A ✓ U I N <br /> SUBCONTRACTOR PHON II �C <br /> SU /y�►//' <br /> SUBCONTRACTOR ADDRESS !► CITY/STATEMP r Y I I v <br /> L;cENSE C•57VC-6i D-0? Other NUMaP ] O EXPIRATION DATE <br /> I <br /> DOMESTIC WELL S9AIPUNG: General Mineral/Coliform Bacteria j43y i I Dibromochloropropane(4392) Arsenic(4393) i <br /> INTENDED USE V Domestic/Private Irrigation/Agricultural Industrial Water quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> if different frog•Owner. Nater System Name Contact Name or Prime Number S\ <br /> TYPE OF WORK Near Well Replacement Well Well A!teration,MOCIflcation Other \ <br /> Monitoring'Nelllsj #of wells Soil!3Crre's 11.1 borings Geotechnical =cf borings <br /> Out-Of-Service Out-OT-Service'Aall Renewal Cross-Connection Repair <br /> New Pum Pump Replacement Pum Rep='r Raise Well Casing <br /> WELL CONStRUCTION !i <br /> Drilling Method Mud Rotary Air Rotary uger Cable-cc. i�dsh Point Other <br /> II <br /> Proposed Well Depth ft Excavation in diareter Open Bottom Gravel Pack/Gravel Size in diameter) <br /> Conductor Casing in diameter : Conductor Casing Depth ft <br /> Well Casino Diameter_:n Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other •�+ <br /> Grout Seal Depth ft Neat Cement(94 lb bag/3-0 gar rater) Sand Cement sack mrx.'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 <br /> oncrete Pedestal Dimensions:Width_ft Length ft Thick in .Christy Box Stove Pipe J\ <br /> PUMP V Submersible Turbine Other 1-P - Pump Set ft Standing Water Levelft <br /> 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 15 I 1 <br /> CURRENT AND ACTIVE WITH THE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS CO NSATION LAWS, <br /> UM 24 HOUR A V INA NO ICE REQUIRE r (INSPECTIONS-PL ASE CALL(209)953-7697Ma <br /> SIGNED DATE <br /> I I I I <br /> I <br /> I <br /> F <br /> i I <br /> AY,A <br /> ; ; � RFcF�FNr <br /> S <br /> i sAN�oA ?019 <br /> l I - LI H ENVRQV/NC T- <br /> DIE ARTME SE ONLY �LTN�pgENT,�'r <br /> Abpucation Aceeotec ay Cate I � RTMEN <br /> Area Employee!D# v`R YL y T <br /> grout inspeC.�cr.6y Date SPECIAL Well Permit <br /> ^p Inspection B Date WAIVER Received <br /> Sud Bonnb I s eLon By Data <br /> ell Dep <br /> D:+nfEN"S 0 e L <br /> W$ OnS clad Wth ft <br /> - rs <br /> PE . SC Receiv d Amount p � <br /> Codes Info i B Cash Remitted Date Service nest# Invoice# WellID# <br /> Et3, 0 7 3h <br /> I i <br /> i <br /> I <br /> j <br /> WELL,P"tP PERMIT <br />