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WELL/FLIM, PERMIT <br /> JAN JOAclum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> �►'I NON-REFUNDA R 1 CALL 209 s-7597 FOR INSPECTION EXPIRES 1 Y FROM DATE ISSUED <br /> VVLj Ca 6 p G <br /> ce ADDRESS Crrylz <br /> CROSS STREET /'•�/�� APINP. I I° <br /> YP Cl ! lil CELSLANQ USE UCA�Oo�# i m <br /> OWNER NAMEIc <br /> PryL/pNN�I(Al( R 7 N <br /> OWNER ADDRESS GITY/$TATE2IP J v I <br /> CONTRACTOR 1 �n PHONE do <br /> ! <br /> _ L4 S (G <br /> CONTRACTOR ADDIRKS � GITYISTATEIZIP� l CF, _ n <br /> II v 1 <br /> SUBCONTRACTOR I PHONE I ti <br /> SUBCONTRACTOR ADORESS I `C1fr1/uhATf Z1 J ! <br /> L,CENSE C-57 C-o! D-09 Othefl) / N ER tY�U EmnFtATioN A41 <br /> DOMESTIC WELL S,.iPUNG: General Mineral/Coliform Bacteria(4391.1 Oibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE V Do,ne5t10/P!IVate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterizatio,, <br /> Public Water System. .I <br /> i1 different bort Jwner. !Jets,System Name Contaa Name Or Phone Number <br /> TYPE OF WORK New Well Replacement well Well Aheration,Mocifeabon Other <br /> MonitoringVells) #of wells Soil SDr!ro:s� it Of bonngs xdbonrgs <br /> �• l / Geotechnical ,•� <br /> Out-Of-Service Out-Ot-Ser ice ball Renewal Cross-Connection Repair <br /> New Pump IPump Replacement P u mc Rec=_c Raise Well Casingi <br /> WELL CONSTRUCTION (1 <br /> Drilling Method Mud Rotary Air Rotary Auger Caole-cr,• o.ish Point Other <br /> Proposed well Depth_ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameters Q <br /> Conductor Casing in diameter i Conductor Casing Depth ft C <br /> Well Casing Diameter_:n Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other _t <br /> Grout Seal Depth ft Neat Cement(94 lb bagr5-16 g_i water) Sand Cement Sack mix/7 gal water <br /> Bentonite(20%solids) Other �7 <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other i <br /> oncrete Pedestal Dimensions:Width_ft _ .h ft Th in .Christy Box Stove Pipe I f <br /> PUMP V Submersible Turbine Other HP Pump Set ft Standing Water Level ft W1 <br /> 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL I P <br /> WORKS TIO�ADE <br /> MIN M 4 HNOTICE REQUIR D FO 1USPECTIONS._•PLE $F CALL(209)f a 697 <br /> 1%( �j�/1 rr� r � ` 6 I <br /> n!GNED ITLE � • DATE <br /> 1;1000, <br /> j ! <br /> I <br /> I I S I I S I <br /> 1 i I I <br /> � I i <br /> j <br /> j <br /> Oct <br /> y <br /> �) A��® <br /> j ` 0 <br /> j <br /> I I I � i E JOgQ� 8 �®�.� <br /> I � <br /> ! I j ""10�7y <br /> �ROH , CpU <br /> -OPPA TME US O' LY �FpgR'zC <br /> Aop'd:uon:,deeotec ay Cate � ' t <br /> A <br /> Area ` Employee!Dt/ /� T <br /> rout Insperlcn ey Date PECIAL Well Permit <br /> pump Inspection Byteres Date 1 ZI WAIVER Received <br /> Soft Boring Inspection By Data Constructed Well Depth IT <br /> J^.•n.t_N�5 <br /> PE ' SC Received j Che / Amount PSN <br /> Co s Into 8 Remittee Date Service Re_qu_est# I Invoice Well fD# <br /> W._ �— <br /> W —� <br /> I <br /> I <br /> - j <br /> WELL iP,wp P hN;-' <br />