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WELL/PUMP PERMIT <br /> SAN JOADuiN CouNTY ENvIRoNMENTAL HEALT«DEPARTMENT 1668 EAsr HAzELToN AVENUE-STOCKTON CA 95205•(209)468-3420 <br /> NON-REFUNDABL nr T CAL x/2'09 953-'69 ^OR INSPECTIONS EXPI S 1 YTW FROM DATE ISSUED <br /> ��8 ADDRESS / CRY <br /> w S7REE" (� /� _ PARCEL SIZE LNN <br /> E�APPu CAn ON C C; <br /> J'NNER NAME " (/l Gt 7 152-I m <br /> w <br /> DwNER ADDRESS / / �- i— 1 <br /> .CN-RAC70R V(� C , 6,1 <br /> :JNTRACTOR ADDRESS V 50 <br /> -_9CONTRACTOR _ N HONE •' l N <br /> >_BCONTRACTOR AD CRESS • • CIIT'W TATE v 1 <br /> _-ENSE .°' -o' D-05 Otn NUMeE /�� �� EXPIRATION 1]Ar ,� <br /> COMESTtc WELLSAMPL;NG_ Genera meraVColrform Bacteria'_3b1, D;bromochloropropane(4392) Arsenic(4393) <br /> N ENDED us E OomesuuP ivate T Imgauon/Agncult,,ral Ineustnal mater Quality Monitoring Sal Sampling/Charade za6on <br /> PuCLc Waver System <br /> it eY.crent rrom J+'r:er. Nater System-Na'a COMMa Name Or PhWe Number <br /> raE OF VYORit Neo':Veil Reolacemert Well Well r.!1r-a;;o-':+ocii.caeon Otter <br /> Morrtonrg Nellts; x of wells Soil 9Cr-_? -_ a of boons' Geotechnical <br /> 064-Cf-Service Weil -_..- =.?rewai Cross.Connection Rene, <br /> _7 p Reolacemen• p _ Raise Well Casino <br /> WEL-CON <br /> Grilling Method Mw Rotan Air Rotary Auger Caaie-cr... =,Sri-oma Omer <br /> Proposed well Depth It Excavaaon r,C;a.-etar Open Bottom Gravel Pack/GravN <br /> Size m Ctame[erI <br /> Conductor Casing in diameter , CC^CLC[Or�a;:lg Ceptn g <br /> iiZA <br /> Weil Casing Diameter_:r. Thickness/Gauge/ASTM Schen Steed Plastic Stainless Steei Other III <br /> Grout Seal Depth ft Neat Cement(94!b baryo5-'G 3_;water) Sand Cement sack rrux/7 gal water 1 �; <br /> Bentonite(20 io solids) Other <br /> Grout Placement Method P,;mped Free Fall Other Retardant:Accelerator(name) <br /> PECEL. Installed By Driller Pump Contractor vtn.er <br /> oncrete Pedestal Dimensions:Width 8 Thick Christy Bot Stove Pipe !I r^1 <br /> o�MP Suomersibie Turbine Other r Pump Set_ ft Standing Water Levei j ft <br /> HEREBY CERTIFY THAT I HAVE PREP THIS APPLICATION AND THAT THE WORK WILL BE DONE IN AI;CORDANCE WITH SAN <br /> _OAOUIN COU ORDINANCES. TATE S, AND RULES ANO REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT D CINE WITH TH ALIFOR A.. ONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL V <br /> 'A/OR S C PENSATION LAWS. <br /> 24 HOUR ANCE OTICE REQUI n= i'VSPECT10 is- LE E CALL;209)9 -T697 ICJQ��I <br /> .i!GNEo <br /> DATE <br /> I <br /> PA Y4 <br /> i <br /> �i <br /> I <br /> pFpq F/VT�7Y <br /> -----T i RTMENT <br /> I � I <br /> I i <br /> I <br /> i <br /> I � I <br /> EPARTMENT US O LY <br /> ACOiiCaCCn A.:GeOfc.:cj �' <br /> Area 'CEmployee!D, <br /> _ra c inspericn By <br /> Dato PECIAL Weil Permit <br /> nspecUon By <br /> 21e WAIVER Received <br /> -cd Bonr,D Inspection By Data <br /> Constructed Well Depth tt <br /> 'E SC Received heck#/ Amount <br /> es Info B Itt¢d ate Perrrii� <br /> Service Re uest# Invoice# Well ID# <br />