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SAN.IOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARWELLIPUMP PERMIT <br /> N �t 1868 EAST FIAZELTON AVENUE-$TOCKTON CA 95205-(209)488-1420 <br /> -FcEFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> (JOB ADDRESS _L 51'3�L] ,,''�ff. /{�� <br /> (CROSS STREET �--tA,T�r'Il� J[J` APNi-O5o'p i Q PARCEL SIZE �/6.U O <br /> LAND USE APPLICATION K <br /> OWNER NAME Abre ani C&a0v'c p <br /> PHONE <br /> OWNER ADDRESS G2-9b I I _ a <br /> �1.A�1 .R 30 <br /> _ CTISTATE2P <br /> CONTRACTOR LC �( rPHONE 522- t 12 <br /> _!} <br /> CONTRACTOR ADDRESS L Lq A.A� f�,(,! __ CITYISTATEZP�y�•� <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS /CITY//$r TATFJZIP_ <br /> X,LICENSE C-57 ]C$1 I.D-09 ❑Other. NUMBER W221(e ExPIRATION DATE 4_3 o"2-z— <br /> DOMESTIC WELL SAMPUNG:X General Mineral/Coliform Bacteria(4391 V, Dibromochloropropane(4392):;Arsenic(4393) <br /> INTENDED USE 7(DomesticfPnvale 71 IrrigaboNAgncullural Industrial ^Water Quality Monitoring ''Soil Sampling/Charactenzalion <br /> Public Water System <br /> ii iblterenl Iron 0w Wet.Syetem Nana CwUICi Name a Phone Number <br /> TYPE OF WORK XNew Well Replacement Well 0 Well Alteration/Modification Other <br /> :.1 Monitonng Well(s) Sof wells D Soil Bonng(s)_ eo1 pcdngs J Geotechnical_0 Of Fogs <br /> Out-Of-Service Well -)Out-Of-Service Well Renewal I Cross-Connection Repair <br /> C New Pump Pump Replacement J Pum2 Repair -1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)<Mud Rotary i Air Rotary Auger 11 Cable Tool )Push Point -1 Other <br /> T <br /> Proposed Well Depth_ft Excavation 1 _in diameter L Open Bottom pe Gravel Pack/Gravel Siz in diameter <br /> Conductor Casing in diameter i Conductor Casing Depth_ ft <br /> Well Casing Diameter 12—in Thickness/Gauge/ASTM Schad Oy C Steel Mastic Stainless Steel :Other <br /> Grout Seal Depth @ Neat Cement(94 Ib bag15.10 gal water) Sand Cement_ _sack mix/7 gal water <br /> >Bentcnile(20%Wids) Other <br /> (Grout Placement Method XPumped -Free Fall [�Other Retardant/Accelerator(name) _ <br /> PEDESTAL Installed By -Driller Jep ump Contractor 7 Other <br /> Concrete Pedestal Dlme sloes Width ft Length ft Thick n Christy Box Stove Pipe <br /> � <br /> _ Hp Pump Set. —R <br /> ft Standing Water Level I <br /> PUMP r'Submersible Turbine .'Other — <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THAND IS PRULES ANDION A REGULATIONS.ND THAT THE NIDRK WILL BE A SO ACCOR <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH AL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 4B HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9 32769-Zy <br /> DATE <br /> TITLE f' <br /> SIGNED <br /> R ENT <br /> Mq SFO <br /> J0,4 Z0?O <br /> e yDQ ,Q co <br /> LNTY <br /> 0 <br /> (HENT <br /> (DEPARTMENT USE ONLY <br /> Data L'1 ! Area Employee IDN <br /> Application Accepted By I] SPECIAL Well Permit <br /> Dale�— <br /> Grout Inspection BY ❑ WAIVER Received <br /> Pump Inspection By Date <br /> Date <br /> Constructed Well Depth R <br /> Soil Boring Inspection By <br /> COMMENTS <br /> Permit/ Invoice S Well IDS <br /> PE SC Received Checks! Date S (vice Re uest S <br /> Amount <br /> Codes cash Remitted <br /> LI LF 11�L- !`�✓ <br /> mac; I M`- <br /> LI?C•a <br /> _.._.,.„ a n.r.• I/`J( //_ \ (L�� WELL M1'VMP PERMIT <br />