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t . , <br /> WELL/PUMP PERMIT <br /> SAN JoAQuw Cotrim Ewmow eirTAL HEALTH DEPARTMENT 1868 EAST HAzrLToN AvEnue-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AWREss /1_ ``� - �•' •G CmrlZ� Q/^!'�!' �J 33(E^ "D� <br /> CROSS$T'RFFr 1.�1 �G P APN T� I J✓J PARCEL SUM (! / LAND Use APPLIrATIONS 0 <br /> OWNER NATE bc)i FYcL e_e/�'� l;l C%_ /y PHONE 6, 1,—�ii 7-—�)-7 m <br /> OWNER ADDRESS �) ./Am i. "7 qnli-1+l t-- CITYISTATEILP Q <br /> CONTRACTOR i" �a�yh•�1t� j � L)OnlI/ PHONE z0Y—5917–p�`7Sl'J <br /> Co .ADtME55 L 4�J 7 Cir`G Ll CrrY/sTATErzm ydie <br /> CA,• <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYISTATEOP <br /> LICENSE G G-57 -0l ❑D-09 E Other NUMBER&jZ � ExrrtunON DATE <br /> DOMESTIC WELL SANPUNG:u General MineraUGoliform Bacteria(4391)G Dibromochloroproparte(4392)a Arsenic(4393) <br /> IN mrm—Liu, stM/Pnvate U IfngaUONAgrk%*Wtal Ll Industrial L Water Quality Monitoring I1 Sod Sampling/Ctw-acteruation <br /> E Public Water System <br /> U ddlemN bora Owner. Water System Narra Carded Name w Phoma Narr4er <br /> TYPE OF WORN 0 New We0 0 Replacement Well 0 Well AHerationlModification C Other <br /> D Monitoring Well(s) Sof wells C Soil Boring(s) sol hodngi 0 Geotechnical s of Iwrings <br /> D Out-OfService Welles D Out-0FServire Well Renewal El <br /> Cross-Connection Repair <br /> 0 New Pu 4'Pum Re acement D Pump Repair P Raise Well Casing <br /> WELL COMTRUCTTON <br /> Drilling Method D MW Rotary D Au Rotary a Auger ❑Cable Tool --'Push Point 7 Other <br /> Proposed Well Depth _ft Excavation in diameter =Open Bottom C Gravel PaddGravel Sae in diameter <br /> Conductor Casing in ILameter I Conductor Casing Depth n <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel ^Plastic F.,Stainless Steel r,Other <br /> Grout Seal Depth ft 7 Neat Cement(94 Ib bagIS-10 gal water) C Sand Cement sack mix17 gal water <br /> C Bentonite(20%Solids) :,Other <br /> Grout Placement Method C Pumped =Free Fall =Other C Retardant I Atxelerator(name) <br /> PEDESTAL Installed By n Driller 0 Pump GonlrWor 0 Other <br /> 0 Concrete Pedestal DDinensions:VVtdth ft Length ft Thick in C Christy Box ❑Stove Pipe <br /> Puhtr —sibleD Turbine C Other HP= Pump Se R Standing Water Level It <br /> I HEREBY CERTIFY THAT 1 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 MY 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 /> P` �?MU.Yr 46 H.JDUR Ar7VANCE NO T(CE REQUiRED FOR NSPECTiONS-PLEASE CALL(209)953-769__7 \\'� <br /> SICNED Trn_E `1h�--- ."fP Li. 'ih-i DATE Y Z <br /> _ c <br /> - Ec MFNT <br /> 1y 2020 <br /> V VAN C <br /> 147- <br /> DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date '-/k� Z OZO Area <br /> _�_ Employee ID# <br /> Grout Inspection By ` Date ❑ SPECIAL Well Permit <br /> Pump Inspection ey �M­S l (�-Lac W t i Date i rd ` b 1j WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Retieirted Checm Amount Date PermiU Invoicr it Well ID# <br /> Codes krto Remitted ServiceR uestlf <br /> AR I <br /> END 43e8 routed 4r1418 WFIL/PUMP PEFiNR <br />