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} WELLIPUMP PERMIT SAN JoAcium COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAaELTON AVENUE.STOCKTON CA 96205 6272(209)4663420 HON-REFuNDAsLEE PPERMrT .r —J_www,s OV.O ehd EXPIRES 1 YEAR FROM DATE IssuEo /� r [CRO5sSTREE'r*.<'ee ADDRESS V.J;," •� 4P t _ •(,7Tyj� A V q I iC�� APM ,/ A r C P.&zE LAND USE APPLICATION//yy��/"�l�y 72 ER NAME ftzeAe&- Br� � yPHONE/�♦ / d/1S3O ERADDRESS eee T CRYISTATEIZP J0 OC./l r0'd/�j(..d//J/J� 4 t/• +�j�\ CONTRACTOR C�Aw4pr' /7 ijac ii eeir ��iy,./I�/C.f Q� PHONE 7/� - f Jr—11 Z J e x �Z J {y{-L'•� {Jrn CONTRACTOR ADoRESa/ gC t /i ;/c Ift•i?e,.lSTAT,P SAG r.,-2 C4 s Cq A e e 71 SUSCONTRACTOWCONSULTANT — n J }� /� PHONE all SUBCONTRACTO//RICONWLTANTADDREn l S!O A. 1 D/JY[ CRYIST.-7-yyi X_Q/1/C/4/ 9' 4 LICENSE IY(-i a C-61 U D-09 a Otter / 111.143/4I E.11RATION DATE 7/;I I.OZO BILu PARTY:.____._ D OWNER D CONTRACTOR j-/IIUBCONTRACPDWCONSULTANR DOMESTIC WELL SAMPLING:0 General MlneraVColVorm Bacteria(4391)0 Dbrornochloropropane(4392)0 Arsenic(4393) INTENDED UaE a DomestICIPdvate 0 hrlgetimJAgricultural a industrial ❑Water Quality Monitoring WSoll s� U Public Water System M dieereru horn Ormer. water System Nrsme Corhd Neau wFnnm NuMwr Mn 'WDRK a New Wall 0 Replacement Wan D Well Alteration/Modification a Other ❑Monitoring Well(s) #of wells ❑Soil owing(s) sOr b6d"ps e"Geotechnipl___c�.aOr bonnpr ❑Out-mervice Well a Out-Of-Service Well Renewal ❑CroWConnectfon Repair ❑New Pump D Pump Replacement n Pump Repalr D Raise Well Casing IftLL CON ON Drilling Method Mud Rotary U Air Rotary /Auger U Cable Tod a Push POIM ❑ Other_ Preposed Well Depth/57-5'0�ft Excevaton u - --- In dlametar o Open Bottom ❑Gravel Pack/Gravel Sizo In diameter D Conductor Geeing In diameter I Conductor Casing Depth ft Well Casing Diameter M ThickneoslGaugalASTM Schad O Steel ❑Plastic D Stainless Steel j Other Grout Seal Depth! -sQ If Aest Cement(94 lb bag15-10 gal wafer) ❑Sand Cement sack mix17 gal water D Bemm� solids)�D Other Grout Placement Method pumped rlFree Fall D Dow D Retardant/Accelerator name) Installed By a Driller a Pump Contractor 0O9Ner L__ ❑Concrete Pedestal[]Dimensions:Widthft Length ft Thick In ❑Ch" as o atom Pips L _ D Submersible❑Turbine D Other HP _ Pump Sat ft Standing Water Leval ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 91 ACCORDANCE WITH SAN JOAQUW COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI 1. 48 H U AD NCE NOTICE REQUIRED FOR IN TIONS-PLEASE CALL(209)953-7697 SIGNED TITLE IQ ��s r DATE �. F-II I f 1-111 Lill IIIIIIIIIII AUG 2019 JOA IRON�. COON LTyO�pM� t IY i A M E N T USIV OWLY Application Accepted Accepted B AreaEmployee IDdC-�'" — Grout Inspection By_ Data 0 PECIAL W@ll Permit Pump Inspection By Date ❑ WAIVER Received Soil Bourg Inspection By Constructed Wall Depth _it COMMENTS PE SC Received C Amount - --- POMW hrVolr�i _ Odp Info_ _ elf I h IternMecL Service RCrest/ Wag IDM 79 G MD43M NMiMe WELLPUL MWrr