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n WELL/PUMP PERMIT <br /> n�1 SAN JOAQUIN COUNTY E.WIRONV.ENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKiON CA 952 <br /> 05-(209)468-3420 <br /> yp/ 'VON-REFUNDAB (b'RMIT L 209 953-7557,zoR INSPECTIONS I PIRES 1 EAR FdQN.DATE ISSUED <br /> .Ja ADDRESS 144 CirvfLP G ,n <br /> j m <br /> CROSS STREET AP l I D <br /> PARCEL SIZEI&Np(15E APPUCATON T1-7r <br /> OWNER ADORE! I I o <br /> OWNER NAME / U �15, T <br /> 1! NONE ✓ 'N <br /> S CI <br /> CITY/STAT P <br /> 'CONTRACTOR �+/ � <br /> �//, /� PHONE <br /> 14 ( <br /> ONTRACTOR ADDRESS �+ / CITY/STA P • `� L,/ ^�+�L <br /> SLECONTRAOTOR I _PF{ONE A J� <br /> S'_BCONTRACTOR ADDRESS I �C (a <br /> jITv/STATEP NIA <br /> -CENSE C-61 0-09 OtherN e / <br /> _ ro <br /> Z " " E%PIRATION DA <br /> 30AAESTIC WattL SJENPUNG: General Mineral/COliform Bact=_na:4351: Oibronochloropropane(4392) Arsenic(4393) <br /> IN ENoep USE V Comes iuPnvate Imgabcn/Agncultural Indstna! Pieter Ouehty Monitoring Soli Sampling/Characterization : <br /> Public beater System_ I <br /> _ it {,?¢rent fror,^,vn;er. avatar Svs;en:,:a-.e <br /> Cortatt Name or Phone Number <br /> ePE OF WOR k New':yeB ReOlacemeri Well well Aura::O`%locifr_eon Other I <br /> Mernormg.VelljS; of wells Sou 9Cr.-gS =ctbonngs. Geotechnical :Cbenn^s <br /> Jut-Of-Service ell Oct-ter-Ser;•ce =Ii Renewal Cross-Connection Repair _ [� <br /> New Pump <br /> Pum Replacement Pu'p+e:z.r Raise Well CasingV <br /> Wel:C.ONsJCTION <br /> D,!Iling Method Muo Retain A,Rotary Auger Caoie'_,;. z�sn Point Other <br /> Proposed Well pepdt h Excavation •r•d.a,ser Open Bottom Gravel Pack/Gravel Size in diameter) <br /> Conductor Casing in diameter CDr:cuctor res.-g.r.'eoth g <br /> Well Casino Diameter_.r, Thickness/Gauge/ASTM Schec Steel Plastic Stainless Steei Other I l n <br /> Grout Seal Depth ft Neat Cement(94/b bag•5-Ti'32i aiat;r) Sand Cement e— , <br /> Bentonite 20�;colics) Other <br /> sack mix!7 gal water I Grout Placement Method Pumped Free Fall Other Retardant!Accelerator(name) <br /> PEDESTAL Installed By Drller Pump Contractor Clher <br /> Concrete Pedestal Dimensions:Width Enc•. ft Thick in .Christy Box S e Pipe I <br /> SUDmersible Turbine Other p Dump Set h Standing Water Level R i <br /> :HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> -:;AQUtN COUNTY 0 DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS i <br /> CURRENT AND AC WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL ' <br /> WORKERS COMP ATION LAWS. <br /> MINIM 4 H ADVANCE NOTICE <br /> REQUIRED F <br /> S!CNED LJ�1 I � LDTIITL° AE J� <br /> A L <br /> l i I I 'i ! I OFAMFN��Nry <br /> I l i I I I I l MFNT <br /> E ARTMGNT UjZ E 0,N LY <br /> "at= f Area o JA7'L�I4��l���f <br /> :roL:!nsPac';cr.gy Employee!C�:j-'�Ls�ff��t' 14 <br /> SPECIAL ell Permit <br /> nspecndn By <br /> yet' <br /> Sul 3pnng Inspealen 3y WAIVER Received <br /> "'.."ISrr-s Dat''— Constructed Well Depth <br /> Pr SC ; Received Ch Amount <br /> Codes Into CashPennN <br /> emitted Date Service RB uest# I Invoice# Well ID# <br /> I f <br /> I <br />