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O"w Weil <br /> ` „� L �C ' <br /> WELL/PUMP PERMIT � •�� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(2091468-3420 1 U:Lf <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES�I rYEAR FROM DATE ISSUED _1 J <br /> JOB ADDRESS 1 R✓V t O IL � CITYIZIP 263(D W <br /> C.- j D <br /> CROSS STREET {�!1_A'<- 1`O Lr�r1�,, APN PARCEL SIZE L�LAND Us APPLICATION#_ �(L/ (� A <br /> OWNER NAMEi1� ynPHONE �D/I'Q' Ly`11;3(d, <br /> � /U 1I 1 <br /> OWNER ADDRESS ( ` 1 J V !V �t� 12A FID C� CITY/STATE(ZIP ISI�1)A . CA 1;3(dO <br /> CONTRACTOR a I �1�(,i�l 2G• /,PHONE ZA9."1/1'5 • �aL2,7ta <br /> CONTRACTOR ADDRESS !51 V 0 3(A(-)L L�Y1 O K/4 CITY/STATE2IP M(,Y"I _C1 a_--l A 9 J J.3 1jj <br /> SUBCONTRACTOR PHONE_ y <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP c f <br /> LICENSE C-57 XC-61 i.D-09 I Other NUMBER 1D L 22� 8(0 EXPIRATION DATE 13) 12,0 2Q <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391):!Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE KDomestidPrivate Q,Irriaation/AgnCultural Industrial :Water Quality Monitoring ,Soil SamplinglCharacterization <br /> :I Public Water System <br /> If dIIN_l Gam O_"' 'A'alut Syxlnm Non< Contact Na—o,Phone Nnmmo: p <br /> TYPE OF WORK ;'!Nev;Well ;Replacement Well Well Alteralion/Modification I I Other &%_QtA� <br /> I Monitoring Well(s) I of wells Soil Bod •rill ngts) 'Geotechnical I Out-Cf-ServicefNell Out-Of-Service'Nell Renewal i Cross-Connection Repair ,� <br /> New Pump Pump Replacement Pump Repair :1 Raise Well Casing 406 [► <br /> WELL CONSTRUCTION t3- C! <br /> Drilling Method Mud Rotary 1 Ar Rotary Auger I I Cable Tool f!Push Point I' Other 1/0O 20/ <br /> Proposed Well Depth It Excavation in diameter I'.Open 9cltom I I Gravel Pack/Gravel Size In diameter FiyV" �(/7N �✓ <br /> Conductor Casing in diameter 7 Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Silted 1 Steel Plastic "Stainless Steel i Other ThOFpq�N�Nry <br /> Grout Seat Depth_ft Neat Cement(94 lb bag13-10 gal veateo i Sand Cemen! sack mix(7 gal water <br /> Bentonite(209A solids) i Other NT <br /> Grout Placement Method , Pumped Free Fall , Other Retardant)Accelerator(name) <br /> PEDESTAL Installed By :I Driller Pump Contractor Other <br /> t Concrete Pedestal Dimensions:'✓'lidth tt Length 1t Thick in Christy Box Stove Pipe <br /> PUMP Submersibles Turbine •Other HP= Pump Sel it Standing Water 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 LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP, SAWS. <br /> MINI M <br /> 7HF �CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNED ' � TITLE - :.�^ DATE I <br /> 1 l <br /> I <br /> I <br /> RT �NT �E O LY / '-,�J <br /> Application Accepted By Area Employee IDA"�`� <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspertinn By '1 Date I L I WAIVER Received <br /> Sail Boring Insoechon By Dale Constructed Well Depth It <br /> COMMENTS <br /> PE I SC Received Check#/ Amount Permit/ <br /> Co Info B ash emitted ,Date 5 rvic Re nest# Invoice# Well 10# <br /> YleLL!PUMP PEftx11T <br />