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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE TON AVENUE-STOCKTON CA 95205•(209)468-3420 <br /> NON-REFUND 8 ERMIT ALL 209 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR ROM DATE ISSUED ! I" <br /> JCB ADDRESS Wkl 12 <br /> CIT`/ <br /> PAM PY <br /> CROSS STREET P 'p APIN 11 -V7 d / PARCEL S '7 (/L/AND Us PPLICATION is <br /> OWNEROn <br /> ,r� ci <br /> NAME ` I ` uV L/� `J,P�l NE�U / lYQ Z qw <br /> CA <br /> OWNER ADDRESS 161 <br /> �.//� L STAT IP ` A^"'(•`, <br /> CONTRACTOR V t 4 S PHON <br /> CONT ADDRES`nS r ___ C11g1 <br /> ;� <br /> SUBCONTRACTOR ,y ' _ PH N `v <br /> SUBCONTRACTOR ADORES CITY/$7gTE1ZlP INIY/� <br /> J,, i <br /> L,cENSE C-57 C-tit D-09 Other NUM R�l3' E—.11.N DA ;I <br /> .DOMESTIC WELLS�QNPUNG: General Mineral/COliform Bactena(4391,1 Olbromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE'V OomestlGPnvate Imgabon/AgnculLual Industnal Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> it CMtrent fro,Owner. Nater System Nem& Ccnt=N9me or Phwe NUmber j <br /> TYPE OF WORK NeA"rVell ReDlacemert Well Well AlteradoniMceifcabcn Other j <br /> Monitonn Vell s of wells Soil Bcnrg:s "cf bongs T d tionngs <br /> 9�� t / Geotechnical <br /> Out-Of-Service at Out-OT-Senr!ce'Lell Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Recair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger C3019-co. push Point Other <br /> Proposed Well Depth ft Excavation r,dmrneter Open Bottom Gravel Pack/Gravel Size in diameter) v\ <br /> Conductor Casing in diameter ; Conductor Casing Deptrfft <br /> Well Casino Diameter_;r. Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other C <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-1G gal nater) Sand Cement Sack mix17 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—f- Len th ftThi in .Christy Box Stove Pi <br /> py <br /> PUMP V Suomersible Turbine Other HP Pump Set ft Standing Water Level it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORKWILL BE DONE IN ACCORDANCE WITH SAN (� <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 15 I ,, <br /> CURRENT WITH TH AUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL i <br /> WO COMPE ATION LAW �1 <br /> MI M 4 HOUR D CE REQUI ED FPR ItNSS�PE/CT,InONt/St/-PLEASE CALL(209)953-7697 <br /> S!GNED TITL'.rl'�'t V L[X /aK 1 DATE <br /> I i �, <br /> PAA� <br /> y�L-- <br /> LVED <br /> SEP <br /> i <br /> 26 <br /> I I <br /> 2019 <br /> NJ <br /> I i i I OAQUIN <br /> NVIRO CoUN <br /> LTH pEpAE�� <br /> P T M E _'� /VT <br /> Aopnbcon Acceptec By Gat��Q <br /> Area Employee ID>:louf­ <br /> Grout Inspect;cr.By oat o SPECIAL Well Permit <br /> ?u^;Inspection By d Dat_—91-hoAf� WAIVER Received <br /> Scil Boring Inspection By DateConstructed Well Depth h <br /> �+finerc-s <br /> PE �&C �Received�; Che��� pe�R/Co es e Service Perm <br /> uesi# I^voice r Well lD# <br /> iag!SL i.2 WP004O f alo e <br /> I i <br /> I <br /> _ ..e ... <br /> 4ELL,P,;:MP PERMIT <br />