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' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVF.NUE-STOCKT ON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRE99V CITYIZIP <br /> CROSS STREET SAA I A`IL 9t)/1�.1 APN ARCEL SIZE AND USE APPLICATION# o <br /> Q IO ( �[LJ Q a <br /> OWNER NAME 1 Q r I Ly1 PHONE 2 i/`1 - (0010• V f) -/ <br /> OWNER ADDRESS l 1 1 5O 1�r- 21 DDA � CITY/STATEILP M1-I nQ(1 t C-8 /9 53(0c' <br /> CONTRACTOR \Jn (7Or6 dg"i IJ-dlU0.-tlO`l�1 I iAc. I�APHONE Z.D9• '/I'/J� • (o.27ta <br /> CONTRACTOR ADDRESS 151- JGC��C. (J✓1P K CITYISTATEIZIP May.rPL(n I CA 953,3 l¢ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIIP� �7 <br /> LICENSE C-57 IXC-61 1'D-09 ii 011ier NUMBER—LD 2 E7(PIRAnONDATE 31 ZQ 2 <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) 1 Dibromochloropropane(4392) :Arsenic(4393) <br /> INTENDED USE (Domestic/Private XIrrigation/Agricultural Industrial Water Quality Monitoring i Sod Sampling/Charactenzalion <br /> Public Water System <br /> I II diff.—I h°m Own°,: Water Syslmn Naim C°hi°cl N-i,,°/Ph°n.,II-A., <br /> I - <br /> TYPE OF WORK I New Well XReplacement Well Well Alleratlon/Modifies lion I I Other <br /> I Monitoring Wells) #of wells Soil Boring(s) a°1°on"Us �Geotechn Cal <br /> I Out-Of-Service Wellut-0l-Service Well Renewal Cross-Connection Repair <br /> 1 New Pum :Pum Replacement Pum Repair Rase Well Casing <br /> WELL CONSTRUCTION " <br /> Drilling Method Mud Rotary i Air Rotary I Auger I Cable Tool . Push Point I Olner <br /> Proposed Well Depth f. Excavation in diameter Open Bottom I Gravel Pack/Gravel Size In diameter <br /> i Conductor Casing In diameter / Conductor Casing Depth tt PAY41 ENT <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched Steel -Plastic i Stainless Steel I Other •O� <br /> Grout Seal Deptn ft I!Neat Cement(94 Ib bag/S10 gal Water) i Sand Cement sack mix(y gal water V eiv <br /> i-Bentonile(20%solids) Other ED <br /> Grout Placement Method ;,Pumped Free Fall i Other Retardant/Accelerator(name) AUG 2 <br /> PEDESTAL Installed By .I Driller i.Pump Contractor :1 Other 2oIJ <br /> Concrete Pedestal i Dimensions:Width It Length It Thick in i Christy Box i Stove Pipa AN JO <br /> AN C <br /> PUMP Submersible)I Turbine I I Other HP Pump Water ft Standing ater Level it I EN1/IRpNMOUNTY <br /> HEREBYENrAj- <br /> JOAQUIN COUNTY ORDINANCES, PREPARED <br /> STATE LAWS THIS <br /> AND RULES AND REGULATIONS.NI ALSO ORK tCERT FY THAT NMYCREQUIRED EL CIENSETH AS Nn L7'H�EPgRT NT <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C0111PEfJSA//T WS. <br /> PJ1 NI MM�H R /MANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)995, 77697 <br /> SIGNED TITLE ^E%� DATE v <br /> I <br /> f <br /> P TMENT U E ON YQ -/[ � `� �/]�� <br /> Application Accepted By Date / Area <br /> -L'�'t� Employee IDW <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By f rirw,i(d L(:,,-L, 9- 2 Dale WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth fl <br /> COMMENTS <br /> PE SC Recetved Check#/ Amount Dale Permit/ Invoice# Well ID# <br /> Codes Into 131 Cash Remitted Servic Re uest# <br /> :# <br /> EHO a3-05,etia°a Inn/16 � � WELL/PUMP PERMIT <br /> �S3S�r3�L <br />