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f 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY E meta ENTAL HEALTH DEPARTMENT 1868 EAST HAmTow AvENue-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PEFwT CALL 209 9,53-7697 FOR INSPECTIONS /j�E�XPPIIRREpS�1�YEAR FROM DATE ISSUED <br /> Joe ADoNEss I c Ov cnYrrr//i/Tl/Z-�� 9 J _7 ,��/� m <br /> APN J rl-)' <br /> CROSS STREET__._. PARCEL SIZE .' 1 k LAND USE AP,P,LIICCATION S J O <br /> OWNER NAME P..E Zy l-S9 —�C, <br /> OWNER ADDRESS 1 r -[+ Crrr/SrATJZ� x <br /> CONTRACTOR PHONE \ t <br /> CONTRACTOR ADDRESS V _ Crtv/STATEIZIP V •C, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDREss CnY/STATTIZIP ) ��; <br /> LICEtrse L VC <br /> C-57 -61 E G-09 L Other NumBrR _J ExpeRATioN DATE LA O� �JU <br /> DorEsne WELL S NG:❑General MineraUColiform Bacteria(4391)a Dibromochloropropane(4392)j Arsenic(4393) <br /> INTENDED Usfi stim'Private Irrigati xVAgriwlhlra7 ,Ind—trial U Water Quality Monitoring a Sol SamplinWCharacter¢ation <br /> G Public Water System <br /> If aneerenn hom owner Wrer SYM—Name Char]Name«Pt—Nwrter <br /> TYPE OR Wath F New Well ❑Replacement Well ❑Well Nteration/Modifimtion 1;Other <br /> G Monitoring Well(s) V of wells a Soil Boring(s) w b d,.p El.Geotechnical a of borings <br /> O:;0f,— rvice�Welll is Out-Of-Service Well Renewal L Cross-Connection Repmr <br /> New Pu i�Fu Replacement <br /> ❑Pump Repair C Raise Well CasLng <br /> WELL CONsTRUCnHoN <br /> Drilling Method C Mild Rotary n An Rotary _Auger Cable Tool D Push Point -- Other <br /> Proposed Well Depth ft Excavation in diameter -'Open Bottom G Gravel Padc/Gravel S¢e in diameter <br /> ::Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidrnes.sfGaugeJASTM Silted rJ Steel E Plastic E Stainless Steil n Other <br /> Grout Seat Depth ft L Neat Cement(94 1b bag15-10 gat water) ❑Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) C Other <br /> Grout Placement Method E Pumped -Free Fall ZI Other Retardant/Accelerator(name) <br /> PEDESTAL Installed BY -D Drt7er ❑Pump Contractor Other <br /> O to Pedestal GDimenslons:Wldth ft Length ft Thick in !:1 Christy Box O Store Pipe <br /> PSO� Submersible❑Turbine C Other HP Pump R Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THISAPPLICATION 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 130ARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LA <br /> P ' ?.1 4 8HE? GTlCE R!_GUiREJ Fr3n IN/S�ECTiONS—PL-f-AS CALL(209)))953-77697 <br /> SIGNED C]TITLE E.,C h r 6 DATE '[! -ZM?n <br /> It <br /> r-W-=---------I IT <br /> YMENT <br /> CEIVED <br /> G 21 2020 <br /> AQUIN COUNTY <br /> RONMENTAL <br /> DEPARTMENT <br /> S <br /> DEPARTMENT USE ONLY / <br /> Application Accepted BY �{� Data J ✓ ,.�_TG;`l Area / / Employee ID3 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By !c.tom:S Lc F, _kl&I. Date 11 1 119 113-1> C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received CItlCkSl AmountIota PeErn <br /> Codes Info ; Invoice It Well IDS <br /> �J <br /> EHO 13-flti rwisatl N74719 <br /> VdF3L/PU1JP PERMIT <br />