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WELL/PUMP PERMIT _ 111111 t7�f-��r�11�If7 D, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '898 EAST HAZELTON AVENUE.STOCKT O�NCA 95205. 1209)4683+12NON-REFUNDAB PERMIT CALL 209 953 7597 FOR INSPECTIONS EXPIR S 1R OM DAT_"LOY U l G( L7 <br /> JOB ADDRESS CITYIZIP m <br /> D <br /> CROSS STREET /`/ APY/11 PARCEL 5¢E D U�5E1L)aP (canonv//,E,-,/�� �'� I I o <br /> IY\ OWNER NAME "r,I f /r1� 1 KIP //PHONE �G� / l!� ' IIf <br /> QWNER AD V OO / / Id CITY/STAT G 1 <br /> CONTRACTOR - ,�,{y f! L4 rn r) PM /t �0�� <br /> CONTRACTOR ADOR��tS//$ / _ CITVISTAT <br /> SUBCONTRACTOR •� 7 ` //P,FIO'1NE/�t <br /> SUBCONTRACTOR ADDRESS CITY.S•r p !y 1" 1 r 1 J /�h <br /> LICENSE C•57 C-6' 9 Oth (/I NUMB _ EXPIRATION DATE `�[ U F_J ' <br /> DOMESTIC WELL UNG: General Mineral/Coliform Bacteria 14391 I Dibromochloropropane(4392) Arsenic(4393) r c� <br /> IN?ENDED USE Domestic/Private Irrigation/Agricultural Industnal Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> it orferent fro--Owner. water System Name Contact Name or Phone Number <br /> TYPE OF WORK New'Nell Reolacement Well Well A!-Lrabo�,Mocifcabon Other <br /> Monitoring'.velgsj #of wells Soil Scrrg S, -- a°f borings Geotechnical e.bo tqs- <br /> Out-Of-Servi¢�bI-- Out-Or-Service sell Renewal Cross-Connection Repair •� <br /> New Pump 1\ Pump ReolacerI Pump Rec=_ir Raise Well Casino <br /> WELL consTRucnoN <br /> Drilling Method Mud Rotary Air Rotary Auger Came-cr. OUSh Point Other <br /> Proposed Well Depth ft Excavation In c ame:er Open Bottom Gravel Pack/Gravel Size_,n diameter) <br /> Conductor Casing in diameter r 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 Ib bag15-'6 gai-water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other I � <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) n <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> C trete Pedestal Dimensions:Width_k L n t ft Thi in .Christy Box Salve Pipe <br /> EU-1- Submersible Turbine Other HP Pump Set ft Standing Water Level <br /> It t� <br /> ! HEREBY CERTIFY HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUY 0 CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP S Tl N LAWS. <br /> MIN M U VANCE NOTICE REQUIRE® ' S'P/E�CTIO�N/nc/I^JPLEA CALL(2Q��(M 7 97 ISIGNED TITL: �' V I / rDATE`! I <br /> iI.I.1i <br /> I ' <br /> I � <br /> i I <br /> I <br /> I qlV <br /> FAj� 019 <br /> �94PHRO1vb COU <br /> I oFp�RNTq�TY <br /> I l i i i t i-, VENT <br /> aP 11TMENT U• E 0,4 LY <br /> Acpiicauon Accepted By Cala <br /> Area Employee Ip#il���ft I4 <br /> Grout insperwn By Date PE-,AL Well Permit <br /> lurrp Inspecton By •-i-i Date WAIVER Received <br /> Soil Soma Inspection By Date Constructed Well Depth It <br /> . .^.•\t=NTS <br /> PE Sc Received 1 AmountPermN <br /> Codes info B as emittec to Service Re Gest# Invoice# I Well ID# <br /> --------------- <br /> i Q 0 <br /> I <br /> i <br /> I <br /> ! <br /> .,° .... WEL,PJMP P"cRM(T <br />