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i <br /> t <br /> t } tT(V <br /> ` MP PERMIT <br /> MYSWELL/PU <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE.Si ocKTON CA 95205.6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.s' ov.orgletild EXPIRES 1 YEAR FROM DATE ISSUED N <br /> �` r N <br /> Joe ADDRESS I t3 CItt/ZtP n <br /> CI:�STREET�a__:�-e�t�,k Miphi ,t <br /> PARCEL SIZE •� LAND USE APPLICATION# z <br /> �-0��23-5—(A J m <br /> C nA�5�2.SiJAUA(f A -ff At i)er+- f_ $ PHONECv <br /> ;OWNER NAME q,� <br /> r <br /> OWNER ADDRESS { CITYISTATEMP <br /> CONTRACTOR �/ \t1 1� TP�H�O/NE OC C�6� l <br /> CONTRACTOR ADDRESS_��Y��• `moi • C CITY/STATEILP \, W Sr lik I 5, <br /> "� <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR)CONSULTANT ADDRESS CITYISTATEILP <br /> LICENSE V1.-57 C$1 D-09 Other NUMBER laExPIRATION DATE <br /> BILUNG PARTY: OWNER :CONTRACTOR :. SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPUNG:. General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE K Domesticiprivete r.:I InigafionlAgricultural =Industrial -.Water Quality Monitoring :I Soil Sampling/Characterization <br /> _Public Water System <br /> It dow."hon Ow ! bleier System Name Conrad Name of Phone Numbor <br /> TYPE PE OF WORK it New Well Replacement Well -:Well AReratiONModificallon Other <br /> -.:Monitoring Well(s) #ofwells ".I Soil Borings) #ofbonngs Geotechnical #ofo""' <br /> OUt-OfService Well -i Out-Of-Service Wen Renewal -"Cross-Connection Repair <br /> ew Pu -_ <br /> Pump Replacement a Pump Repair L'Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _Mud Rotary ::Air Rotary i Auger . Cable Tool Push Point - Other AYE yE <br /> Proposed Well Depth_ft Excavation in diameter ;Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth R Rec`/V� <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched C Steel Plastic Stainless Steel Other4.4 <br /> Grout Seal Depth ft Neat Cement(941b bagV5-10 gal water) - Sand Cement saCR mix!7 gat water �4 U� p 5 <br /> Bentonite(20%solids) Other �Q��� 2iD19 <br /> Grout Placement Method -Pumped : Free Fall Other Retardant I Accelerator(name) -'N JO `J <br /> PEDESTAL installed By Driller Pump Contactor _ Other qQV� C <br /> Concrete Pedestal_Dimensions:Width_R Length R Thick in _Christy Box J Stove Pipe H FN�RON N COU <br /> FAlty MEN 1Y <br /> PUNP Submersible Turbine Other HP Pump Set R Standing Water Level It �EPAR TM N <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN r <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> rjl,!N?,tkIMJ4g(?CU,q OVANCE N0110E REQUIRED FOR INSPECTIONS-PLEASE CALL(249)953-7697 <br /> SIGN—, TITLEDATE R f I <br /> I LL <br /> VvN�►l�S rCrS. <br /> low <br /> P#TMENT E NLY <br /> Application Accepted By v DateArea Employee ID# <br /> sP Y <br /> Grout Inspection B Date PECIAL Wei)Permit <br /> Pump Inspection By �llOt C�Z1. -rll Dale WAIVER R8C01V6d <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMIAENTSCPYICj 't'kA�li�"� <br /> PE Be Received CheetaW Amount D to Pernllt/ Invoice# Well IDiF <br /> C Info Cash emitted Service Request# <br /> 0 <br /> NELL/PUMP PERMn <br /> EHDQ7 a 01112e19 n_ ��/ �Y73 <br />