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WELLIPUMP PERMIT <br /> ` SAN Jr1AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1$68 EAST HAM TON AVENUE•STOCKTON CA 95205•(209)46S3q.{Of <br /> NON-REFUNOAe CA 209 933-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM D E I5s`UlEED <br /> J09 ADDRESS crr ,rzS <br /> 11M <br /> CROSS STREE2T r'N/7► `— APN Z //O' t D <br /> �j I)j PARCEL SIZE `L'A(��t)))(4JJJLNrDµU(yS�EA.�PP/U�\CATION;"r I�A <br /> 'OWNER NAa1E 1/s / O f/ 1 Lf—� PM(OJ'N`C <br /> OWNER ADDRESS'­/ G t ✓t )yCCI JA P ` { <br /> CONTRACTOR _ �r H V r -- 7 PHONg " <br /> .CONTRACTOR ApORESSj, _t 5 �'+ CITYISTATE01, �di v'y� t . <br /> SUBCONTRACTOR f• <br /> 1 A <br /> SUBCONTRACTOR ADDRESSCITYISTATEral' If �I <br /> LICENSE C-67 C-61 0-09 Other 2 NU 1/t7 EXPIRATION DA <br /> DOMESTIC WELL SA,►tPUNG: General Mineral/Coliform Bacteria(4391) Dibramochloropropane(4392) Arsenic(4393) <br /> INTENDED UsE OomesdGPrivate ImgatioNAgricult.ual Industrial Water Quality Monitoring Soil Sampling/Charactenzation (� <br /> ,f� Public Water <br /> cSystem <br /> �I <br /> ' • ;I ebic "Vr Owner uVd;er SyStBm Name Contact Name or Pnone Number <br /> TYPE OF WORK WK.-Well Welt Replacement Well Well Alterat+or.,Moo fcat+on Other <br /> Monitoring Wells) i of wells Sod aoring;s i °°f°O""sc Geotecnnical *of Donny I^y <br /> � /p.Lt-op Service Well Pump <br /> Repair Well Renewal Grose Well Casing n Repair I <br /> tPv®A_J{I"' V New Pump Pump Replacement Fump Repair Raise Well Casing I <br /> WELL CONSTRUCTION <br /> !Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth h Excavation in C.arneter Open Bottom Gravel Pack!Gravel Size in diameter) <br /> Conductor Casing in diameter r Conbuctor Casing Depth h <br /> Well Casing Diameter_in ThicknesslGaugeIASTM Scheo Steel Plastic Stainless Steel Other <br /> Grout Seat Depth It Neat Cement(94 lb bag15-10 gai water) Sand Cement sack mix/7 gal water) <br /> 9entorite(20%solids) Other <br /> Grout Placement Method Pumped Free I Other Retardant i Accelerator(name) <br /> ;PEDESTAL. Installed By Driller VPump Contractor Other ; <br /> ancrete Pedestal Dimensions:Width it Length=it Thitit W in Christy Bax Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump S it StandingWater Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTR CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK ENSATION AWS, C,.V <br /> M 24 HP R NOTI RE ED FOR IN.SPEC.Ti0 S t.¢)-PLEASE CALL(2091954-769 <br /> R 7 <br /> I <br /> � <br /> $I LE DATE <br /> I I <br /> ! I <br /> �►�y <br /> `i► �� ll <br /> fAy4? <br /> 2� <br /> Lou,NrY <br /> I I P TME'N7 CyNLY <br /> Applicaton Accepted By / Gate'y Gr� -"-+-- Area_? Employee IDki�W <br /> Grout Inspection By tt"� _''�a'Date _ PECIAL Well Permit <br /> Pump Inspection By N� ��Y� Date ^��� WAIVER Received <br /> Soil Boning inspecuen By p !f Data Constructed Well Depth tt <br /> COMMENTS /�j(' z yrr)r_ tT� � ! 1 t a /' f <br /> PE Sc Received he Amount Permit/ <br /> o s Irtfa I B ! s mined ; <br /> Date ervica"to. Invoice Well 0# J <br /> + <br /> i <br /> WEU 1P'JMP PERMIT <br />