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WELL/ U P PERMIT <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1068 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)460-3420 <br /> NON-REFUNDABLE PERMITTwWw. or lehd /��EXPIIRES 1 YEAR FROM DATE ISSUED 3y3 <br /> Joe ADDRESS �OO ` VL _ CITYIZIP Aloe �CCI rd <br /> D <br /> CROSS STREET I r• () APN ZZ-� &l0 I PARCEL SIZE I�'� LAND USF.APPLICATION# P <br /> .Q1:�Irc 5 PHONE <br /> OWNER NAME UL+T _ -71 <br /> r y4 95 <br /> 2 i L /1 <br /> OWNER ADDRESS c �r-CCS 1•�L CITVISTATEIZIP •'•*kI c l,I- r A 4 -334 <br /> CONTRACTOR �7{III IJ r,l ��i��C PHO E 52-2 Vj L2 <br /> CONTRACTOR ADDRESS_11b�.�s r4.�1• CITVISTATEIZIPO G <br /> SUBCONTRACTOR/CONSULTANT PHO E <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYIISS,'r�A�TEIZIP (, <br /> LICENSEC-57 D C-61 U D-09 U Other NUMBER �+� ExPIRATION DATE 7' ( Z <br /> BILLING PARTY: 1 OWNER I I CONTRACTOR !SUBCONTRACTORICONSULTANT i <br /> 'DOMESTIC WELL SAMPLING:!I General Mineral/Coliform Bacteria(4391)I:'1 Dibromochloropropane(4392); i Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soll Sampling/Characterization <br /> 0 Public Water System Contact N me or Phone Number <br /> If dlHereul from Ownec —Wale,System Name <br /> TYPE OF WORK (New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other_T nor borings <br /> ❑Monitoring Wells) <br /> #of wells 0 Soil Boring(s) a or borings 0 Geo echnical <br /> II Out-Of-Service Well D OW-Of-Service Well Renewal 0 Cross-Conneclio Repair <br /> D New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method XMud C,,,Air Rotary 0 Auger 0 Cable Tool. O Push Point 0 Other <br /> Proposed Well Depth it Excavation In diameter 0 Open Bottom )(Gravel Oack/Gravel Size in diameter <br /> 0 Conductor CyIng In diameter / Conductor Casing Depth it <br /> Well Casing Dlameler j&in Thickness/Gauge/ASTM Sched '2—y0 0 Steel 'XI'laslic n Stainless Steel 0 Other <br /> Grout Seal DeplhS0 it 0 Neal Cement(94 11)bag/5-10 gal water) 0 Sand Cement sack mix17 gal water <br /> �(Benl nlle(20%solids) 0 Other <br /> Grout Placement Method Pumped 0 Free Fall 0 Other U Retardant/Accelerator(nse) <br /> PEDESTAL Installed By O Driller Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimenslons:Width it Length ft Thick In 0 Christy Box U Stove Pipe <br /> Pump 0 Submersible Turbine 0 Other HP Pump Set it Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI' THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> I ALSO CURRENT A DN CTIVEIWITH THE CENSE IS <br /> SCALFORNIA CONTRACTORS TATE LAWS, AND RULES NSTATEU LICENSE BOARD AND THIAT,,I AM IFTHAT N REQUIRED (WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> hill% 1�M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 s <br /> SIGNED <br /> � � TITLE Ort-1K.4!I DATE 2- <br /> - r <br /> — D <br /> 0 <br /> I N <br /> R <br /> PATMENT US O IL.Y /� <br /> Gyj Dale L� <br /> Area v` Employee ID# <br /> Application Accepted By <br /> Grout Inspection By_ <br /> Date I 1 PECIAL Well Permit <br /> '� WAIVER Received <br /> Pump Inspection By <br /> Date <br /> Soil Boring Inspection By <br /> Dale Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Recelved Check#/ Amount DalePermiU Invoice# Well ID# <br /> Codes Info B as 1 Remitted Service Reyllest# <br /> !Z Ili 1 -WPOW q ao, <br /> WELL/PUMP PERMIT <br /> Er1043-06 61/112019 <br />