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• WELUPUMP PERMIT <br /> SA14 JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZFLTON AVENUE-STOCKTON CA 96206-(209)468-1420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7$97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADORPs6 m <br /> CROSS STREET!e//71CiL G�✓J'y�/Y AIP�N /(20- <br /> 0- PARCEL S¢E 1 MD UBE APPL{G1WM# <br /> OWNER NAME S�r' \)r 1?Yi7 P[/Y L] r�6 i�/7 PHONE `��C >a t? �n <br /> OWNER ADDREsB ! 3-1( s RC� t j( 'e 1 " V <br /> _ CiTY1STATEJZIP Y/rQ?7�'CC� CQ / ` <br /> CONTRACTOR _1,c / 1X T't(' {�1a^' l / JPH�ONE <br /> CONTRACTOR ADDRESS .rS <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDREss CITYISTATE1Z1P c� / <br /> IUCENSE C-57 " G61 D-09 _ Other NUMBER ZLS: �?�'" ExPtRATION DATE 1 ZO <br /> DOMESTIC WELL SAMPLrNGI tj General Mineral/Coliform Bacteria(4391) Dibrcmochloropropane(4392)❑Arsenic(4393) ` <br /> INTENDED USE Comesticip"vate !::Inigation/Agriaukural ❑Industrial --Water Quality Monitoring =Sod SamplingfCharacterization <br /> -:Public Water System <br /> �` Ir drterem Imre Owner: vy t.SrAn n Nem Carted Name a Phare Number <br /> TYPE OF WORK O New Well :J Replacement Wei -Well Aieration/Modificabon Other <br /> O Monitoring Wells) #ofveis -Soil Boring(s) rarbmaps _Geotechnical rcthan"as <br /> 'I 9u1-Of-Service Well :. Out-O!-Service Well Renewal =Crass-Connection Repair <br /> flew Pump PTanp Replacement Pump Repa r Rase Wdl Ces ng <br /> (WELL CONSTRUCT)} ` <br /> Drilling Method _.Mud Rotary Air Rotary .Auger -Cable Tod : Push Pohl _ Other <br /> Proposed Well Depth it Excavation in diameter -: Open Bottom _:Gravel PackJGravel Sae in diameter <br /> - Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic a StaMless Steel I Other <br /> Grout Seal Depth ft .-i Neat Cement(94 1b bage1i-10 gal water) :: Sand Cement sack mrx17 gal water <br /> Bentonite(20%solids) ,J Other <br /> Grout Placement Method - Pumped J Free Fall Other - Retardant I Accelerator(name) <br /> PEDESTAL Installed By - Driller n Pump Contractor Other yl <br /> Concrete Pedestal uDimenslons*Width ft Length ft Thick in ❑Christy Box Stave Pipe <br /> PUMP Ise Submersible.: Turbine :i Other HP__,?_ Pump Stt___2 ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MIN H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.-7697 <br /> SIGNED + TITLE DATE 70 l <br /> f <br /> Ali <br /> qRT��� TY <br /> NT <br /> i <br /> i <br /> Il1ENT AS 0 LY <br /> Application Accepted By Dale /,/Ile, Areae Employee <br /> Grout Inspection By Date ': SPECIAL Well Permit <br /> Pump Inspection By - "r Date 11 1`1 WAIVER Received <br /> Sal Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Received Crew Amount Date Service # Well ID# <br /> Info ash emlttad Service Request# <br /> P <br /> EM]13U M1110 17YTy, <br /> (EI <br /> 17 WELLNPJMPPERMn <br />