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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENv2RONMENTAL HEALTH DEPARTMERT 1968 EAST HAZELToN AvE.NUE-STOCKTON CA 98206-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697f FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> "G <br /> Joe ADDRESS 1]LI L �. �a. t wl 1C {Q r+G CITY/nP I�✓✓r4✓1+eco• ( S 33/ <br /> G1068 STREEY ,/�y v APNr'/ PARCEL SME�'{ ND Use APPLICATION# o <br /> O m <br /> OWNER NAME =�h f�O dL Fae P. <br /> PHONE q/6-6 yo - <br /> OWNER AODRl 'tt Z { jCII,. .,I, 7Y{ , <br /> C f✓2 CfTY/STATEIIIP E, Y{, J •�✓7, z <br /> CONTRACTOR -12-, 13,,-+SL it a✓`\ �%J,J/ PHONE /i�(-6s zQ-C9t5 r7a <br /> CONTRACTOR ADDRESS S S T <br /> b t (-eQ m e r i - CTTY/STATEOP I N'7n v i tom) /,.] 3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS L1/ V 7�Q ISTATErAP <br /> (LICENSE C-57 C-6t J D-09 Otter NUMBER a u EXPIRATIONDATE <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bactena(4381)Ll Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENnEn UsF DomestiriPm/ate U Imgation/Agncultural D Industrial L Water Quality Monitoring ::Sag SamplivVCharacterization <br /> Public Water System <br /> If difMent from Dwner. Water Systd None C.nlad Nem.or Ph—e hAlrrber <br /> TYPE OF WORK )6ew Wel L�RBplacemett V/ell -_Wei Alteration/Modification _Other <br /> Monitoring Wells) #of Nets -Sal Bonng(s) s or ba tis Geotec hniCet a of boring. <br /> O Out-Ol-Sevice Wel =Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pu "Pump Replacement -Pump Repair Raise Well Casing <br /> WELL CON5TRUC170N <br /> Drilling Method -Mud Rotary D Air Rotary -Auger :_ Cable Too! :Push Point :_ Other <br /> Proposed Well Oepth R Excavation in diameter Open Bottom Gravel PacklGravel Sae in diameter <br /> Conductor Casing in diametw 1 Conductor Casing Depth R <br /> Well Casing Diameter_in ThidcnesslGauge/ASTM Sched "I Steel P1aAC L?Slafnless Steel -Other <br /> Grout Seal Depth R E Neat Cement(941b bagl5-10 gal water _ Sand Cement sack mix/7 gal water <br /> Bentonite(20%sofds) D Otter <br /> Grout Placement Method -- Pumped ZI Frae Fall ,-:Otter Retardant/Accelerator(name) <br /> PEOE6TAL Installed By -Driller C Pump Contractor I! Other <br /> G Concrete Pedestal EDimensions:Width R Length R TThick in C Christy Box Stove Pipe <br /> PUMP Submersible_Turbine C,Other HPPump Set R Standing Wata Level ft <br /> I 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 IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINiMU UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> STONED TITLE_ (! W a-e✓ DATE 2 t <br /> AIIa� <br /> a� l <br /> i yyEC N.r <br /> C 'veo <br /> i AN <br /> SEP Z 2019 <br /> �AQUIN C <br /> EANVHDE AE IAL,} , <br /> FFP RTMENT U E NLY CC//��//,��//� <br /> Application Accepted By Oa Area Employee IDS L�1lJ/�l'V/�F 4 <br /> Grout Inspection By (� Oete SPECIAL Well Permit <br /> � <br /> Pump Inspection By 1ddN3 tCl a��te `'O }�T� _ WAIVER Received <br /> Sal Boring,Inspection By It ,Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received Chaek#! Amount DaW Penn V Invoice# Wel{{D# <br /> Cod into ash Remitted Service Re uest# <br /> [HD{3-(G WELL NUMP PERMIT <br />