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10ISDI <br /> WELL/PUMP PERMIT Ute{ Si1-e T7. -Z3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTAIFNT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 306I CITY(ZIP 47f A'C�v� D/x m <br /> Cn m etz. �d Nlr67 <br /> CROSS STREET AP o'�; ARCEL SIZE�Q-S*ANO USE AP/P�LICALT�ON(#� n A <br /> OWNER NAME �KDBtS;� ' n's PHONE)09`1 90-1 �(•/S�vI ?? <br /> OWNER ADDRESS I(NO CCAr+e� K-G CITYISTATEmP �rrjL�4 Jv-'7/L/fit CA\ q5 L,J <br /> CONTRACTOR Q 1CO+�t � \DPHONE ?- 1• (/rI'/J� (o2�(- <br /> CONTRACTOR ADDRESS �)tl(� �(�LIG OYt O. CITYISTATE(ZIP Mc,_VL�e[Iti i A ��5 a3(p <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY{I,,SEE <br /> �TAT701'/ <br /> LICENSE i I C-57 C-61 I D-09 I I Othef NUMBER /� `� / /l0 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: I General MinerallCCl iform Bacteria(4391) I Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE a DomeslicJPriv-ate C) IRIgabonlAgrlclillural I Indusldal I Water Quality Monitoring �Soil SamplinglCharactenzation <br /> Public Water System <br /> Il dlffannl tram 0-1: Wales Systam Nanw anlucl Hama of Pl,onu NunL r <br /> TYPE OF WORK I New Well i;Replacement Well Well Alteration/Modifiicalion i!Other <br /> I I Monitoring Wells) #of Wells Soil Bodng(s) 0 of 6odop , Geolechnical x of mrm(19 <br /> I I Out-Of-Service W U Out-01-Service'dvell Renewal I!Cross-Connection Repair <br /> I I New Pum Pum Replacement Pump Repair Il Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary :.I Air Rotary I Auger i I Cable Teo[ I I Push Point 1: Other <br /> Proposed Well Depth ft Excavation in diameter f'Open Bottom �!Gravel Pack/Gravel Size In diameter <br /> Conductor Casing In diameter I Conductor Casing Depth h <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Staled i.Steel i Plastic i Stainless Steel Other <br /> Grout Seat Depth ft I Neal Cement(94 lb bag/570 gal water) i Sand Cement sack mix,9 gal water <br /> U Bentonite(20%solids) I Other <br /> Grout Placement Method t_Pumped Free Fall :Other i Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller .:Pump Contractor I Other <br /> ::Concrete Pedestal!':Dimensions:Width h Length It Thick in I Christy Box Stove Pipe <br /> PUMP !:I Submersible I Turbine Cther HP Pump Set R 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 tAC�TIV.E WITH THE LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMWS. <br /> PdINI R /ynNCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED r /�` TITLE DATE <br /> /` <br /> veb <br /> a <br /> J 2019 <br /> QUIN <br /> i u"O/vi j��Nry <br /> IT <br /> P T M E N T U E NLY ��/� <br /> Applicallon Accepted By Dale A Area Employee ID# +'Ir�`"vl <br /> Grout Inspection By Date PEc1AL Well Permit <br /> Pump Inspection By ter.. 6vi Date `t I WAIVER Received <br /> Soil Boring Inspection By ate Constructed Well Depth fi <br /> CQMMENTS <br /> d <br /> PE Sc Received Check#I Amount Dle Permit, Invoice# Well ID# <br /> C es Info sh emitted Service Reuest# <br /> l <br /> C'— <br /> E.0 13.6—1—d urnne //✓/�/(�(''��A �/� "�R T WELL MUMP PERMIT <br />