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�( 11 <br /> WELLlPU3 r PERMIT �'�� lCAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4K: <br /> NON-REFUND IT CALL 209 95"-7697 FOR INSPECTIONSJS�r EXPI ES 1 Y FROM DA E ISSUED <br /> jC8 ADORESS �� CITY/jP` ) (-010r) j m <br /> CROSS STREET APN PARCEL SIZELANG USE A Yr <br /> _ n <br /> '` 1 m <br /> OWNERNAME "� / D +U(- I19� /�/P7�NO�)NE �A <br /> OWNER ADDR S t Hx CITr/S7A P • ' LA J� <br /> aoCONTRACTOR I-V/ ( ! F7Hppr (,/ \p�" <br /> ( M cc <br /> I \' <br /> CONTRACTOR ADORES$ V� I I GI STA <br /> SLBCONTRACTOR IM\`II/1 P�0 - <br /> SLECONTRACTOR ADORE VC <br /> / � $7q p • II� <br /> UCENSE ;-67 -6t D-09 Othef NUN ER EXPIRAT10N DAT 1 <br /> 11 <br /> 30ME5TIC WELL$ UNG: General Mineral/Coliform Bacteria(4351 l Dibromochbropropane(4392) Arsenic(4393) <br /> (WENDED USE V Dcmestic/pnvate imgation/Agricultural Industnai Nater Quality Monitoring Soil Sampling/Characterization i <br /> Public Water System I <br /> i1 aAterenl fro'Owner. Water SyStem Name Coriiaat Name or Phone Number i <br /> TYPE OF WORE New Well Replacement Well Well Nteration,Mceif cation Other <br /> b—It Monitoring�.VeutsjT#of well Soil 3.r.r.;; a d^ Geotecnniral <br /> Out-Of-Service WDTf Out-O*-Senice v,all Renewal Cross-Connection Repair !' <br /> New Pump /Pump of <br /> Pump pec=r Raise Weil Casing <br /> WELL CONEMUCnON <br /> Drilling Method MLd Rotary Air Rotary Auger Caole-cc. Dash Point Other <br /> Proposed Well Depth ft Excavation �n dlane:er Open Bottom Gravel Pack/Gravel Size In diameter) t-t� <br /> Conductor Casing in diameter : Conductor Casing Depth <br /> Well Casino Diameter_,n Thickness/GaugelASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagr8-?v ga;warer) Sand Cement sack mix.7 gal water S <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 Len th ft Thick in .Christy Box Stove Pipe ) <br /> PUMP Submersible Turbine Other HP J Pump S-tt=ft Standing Water Level it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN C U ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS .� <br /> CURRENT CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL ( n <br /> WORKERS M ENSATI LAWS. <br /> M M 2 . OUR ADVANCE NOTICE REQUIRED E MSPECTIONS-PLEASE CALL(20 7697W <br /> 5!eN TIT (N` Y L lX m�iL'Y / DATE \V <br /> I I I l I C <br /> t 11 <br /> i I <br /> i <br /> , I <br /> T i I <br /> 84y <br /> 1 FF <br /> cou <br /> IN, ic/AJ <br /> FNVjAQ�IN <br /> ! I y�CT N DEPART r CNrY <br /> 'E Qf A R 7 M E U SIE ONLY /yJEN <br /> r <br /> Applidauon Accepted dy Date r Ila <br /> Area*'10 Employee IDxfti'alkk <br /> Grout inspecticn 85 Dat: SPECIAL Well Permit <br /> �_mp Inspectwn Byr�ssYinar -A-Picn Date q WAIVER Received <br /> '1— V <br /> Soil Bonno Inspection By Data Constructed Weil Depth ft <br /> PE SC Received C Amount Permit/ <br /> Codes Info asRemitted Date Service Re uest# Invoice# Well ID# <br /> 8 n)P�Q400R5 i -- <br /> I i <br /> WELL,P,;:d"n==KNIT <br />