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c * 5 <br /> WELUPUMP PERMIT <br /> SAN JOAcum Couwtt E mRowAENTAL HEALTH DEPARTMErrT 1868 EAST HAzELTOw AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDREss 2�(3 7- S. !=r Tel-er ick /til - Cm rzR AL •, 95--74` 6 <br /> CROSS STREETO 1`('r)r �,/l' API as V C o 11 PARCEL SIZE - LAND UsE ArpucAmow 3 g <br /> .7 'OWNER NAAM -2 PHONE `Cj •,��C�. GV/` <br /> OWNERAD5 ?0F1ey4ey c Ave c1rY1STATrZW L1, <br /> CONTRACTOR V'Qilq.,II / PHONE &5 —34K <br /> � <br /> F <br /> 4v-`Li CRY/STAiEFLw0c)i ] <br /> SUBCONTRACTOR � <br /> b_ <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CrTYMTATE/ZIP 77 1 <br /> LIcENsE L G-57 -51 L D-09 --Other NUMBER Z' ExpaeAnc)N DATE 3A:] <br /> DOMESTIC WELL S PLUG:_General MineraYColiform Bacteria(4391)G Dibromochloropropane(4392)D Arsenic(4393) <br /> INTeRoeo use .Damesti il`d-,te o IrrigatpNggricWtural -Indusvtal I:Vvarer Cluatiry Monitoring ❑Sod Samphngrcharactermation <br /> E Public Water System <br /> It di&zew hom Owner Water Sysfem Name Gonial N.—a Ph—M.", <br /> TYPE OF WORK �-,New Well D Replacement Well D Well AReration/Modificafion D Other <br /> E.MonitoringWelf(s) IIofwells =SalBoring(s) aahodovs D Geotechnical ;°rbOdrW <br /> F'Out-Of-Service Well.,-" Out-Of-Service Well Renewal n Crass--Connection Repair <br /> D New Pump LPGmpReplacement G Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary ❑Air Rotary is Auger +?Cable Tool Push Point D Other <br /> Proposed Well Depthft Excavation in diameter D Open Bottom D Gravel PacVGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thicliness/Gauge/ASTM Sched D Steel D Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth It ❑Neat Cement(94 lb bag/5r10 gal water) ❑Sand Cement sack mixf7 gal water <br /> D Bentonite(20%solids) D Other <br /> Grout Placement Method :;Pumped ❑Free Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By G Duller ❑Pump Contractor D+ Other <br /> ❑Concrete Pedestal CDimensfons:Width ft Length ft Thick in L Christy Box ❑Stove Pipe <br /> Pump Submersible Turbine D Other HP 'L Pump Set ft Standing Water Level 7 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 IKY 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 /> F ' iPi3UM g' 011R ADVANCE NOTICE REQUIRED FOR iNSPECTiONS-PLEASE CALL(209)953-7697 <br /> 953-7697 <br /> SMMEo TrrtE �r5>.'(�Mi�'!:i-L%1 t'./` DATE `7—/7`Zr—'Cc <br /> T <br /> - RE YMF <br /> o R <br /> \ pgRT175 <br /> ��NTY <br /> MFNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �/` ` Date ��d'-t�� - Area 2 Employee iD# <br /> Grout Inspection By _ r,, Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �-t`r n. S(� li xY L Y�J i Date��jt(C Q.L.' ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received ctle" Amount Date Permit/ Invoice -_- Well ID* <br /> Codes Info Cas Remitted Service Request# <br /> qlsvi <br /> Eno a39e reined alone wET.LmVnuP PERNrr <br /> � /67g3/30v <br />