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E � <br /> Pt - �muiQ�a:- e►��`¢��ands�p�c�-p�rmu� <br /> Glad ���Il�rs d rzc#�Y' C1A'1�yEL�/PERMIT" A`L/J�i(.p <br /> SAN JOAOUIN COUNTY ENveRo NMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE.STOCKTS4 75205.6232,7 9)468-3420 <br /> NON-REFUNDA-'a o`F-QapT j�L _ / , T w.js Rov.org/ehd FXPIR SVVV1VVVYEAR FROM DATE ISSUED <br /> JOBADwtE—as -307 r�' eTT1�1i e I-' CITYZP pl�i�►f ,.�tyf I� <br /> ��.� 1y, � 143 0��''7 r pn <br /> CROSS STREET ,h T r'i J AP��,(} ✓ PARCEL SIZE USE A}➢/yP�LICA�,i,.b,�� f S <br /> J Vt r CSW• QO <br /> OWNER NAME rpt/"t� vt Q PHONE <br /> OWNER ADDRESS r Y V 12 CITY TATE IP r f.440 <br /> CONTRACTOR .�}-�J�/// G <br /> CONTRACTOR ADDRESSZ60 RUL/n� y� CRY/STATE ZP P <br /> VPHONE <br /> URL Ll <br /> SVBCONTRACTOR/CONSULTANT CardoIIC' PH N O <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1`'1 7- f5kC �1 CITYISTATE/ZIP I •S <br /> LICENSE A-57 G61 D-09 -Oth8 <br /> er NUMBER EXPWATIO ATE <br /> BILUNG PARTY: _OWNER _.CONTRACTOR SUBCONTRACTOR/CON3uLTAN <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) D ibromochlorc propane(4392)-Amenia(4393) <br /> INTENDED USE Dome$Ic/Privale -Irrigal riAgricLl ural _Industrial Water Quality Monitoring .. Soil Sampling/Cherederization <br /> Public Water System <br /> if i ff—t tom Owner: WeW Syetem Narre Contact Nana er Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) III of wells SoilBoring(s) aofborings - Geotechnical tlwboiw. <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _New Pump _Pump Replacement _Pump Repay - Raise Well Casing _ <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger :Cable Tool Push Point -I Other <br /> Proposed Well Depth '- ' H Excavation in diameter Open Bot;tjn Gravel PaCk/Gravel Size in diameter <br /> Conductor Caa�l� —in diameter / Conductor Casing Depth ft <br /> Well Casing Diamete Qn 'Rrcknes3 GaugeIASTM Schad Steel Plastic Stainless Steel ,Other <br /> Grout 5ea1 DepthA- 1 A VNeat Cement(94 lb bag/5-10 gal wafer -Sand Cement sack mrxll gal water <br /> [-Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Otherla nt/Accelerator(name) <br /> PEDESTAL Installed By ^Driller ^Pump Contractor - Other <br /> Concrete Pedestal_Dimensions:Width_ft Length ft Thick in Chrlsty Box Stove Pipe <br /> PuNP Submersible_Turbine _Other HP_ Pump Set _ ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQLIN COUNTY ORDIWWCEt STATE LAWS,AND RULES AND RECIULATIONS. I AL30 CERTIFY THAT MT REEL Qcn LICENSE IS <br /> CUFAENT AND ACTIVE WITN THE CALIFORNIA CON77IACTORB STATE LICENSE BOARD AND THAT 1 AM N =MjlANCE WnM ALL <br /> WORKERS COMPENSATION LAWS. <br /> AA11MMU AS HOUR V NCE NOTICE REQUIRED F INSPEC ON -PL SE CALL(209)36 -76 7 <br /> 0 T11I8 DATE <br /> 04 <br /> FLS �3 `LO <br /> DEPARTMENT USE ONLY <br /> N� Application Accepted By i Dab pl ib Ara. I GfG/ Employee ID# <br /> Grout Inspection By Dela 0 SPECIAL Well Permit <br /> Pump Inspection By Dote WAIVER Received <br /> Soil Boring Inspection By(-Q-2x2. d�4rp®�\�/I.n pay \ `; �L.1 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codas Info Cas Remitted <br /> rL JL <br /> EHD43d9 5111rC19 <br /> WELL/PUMP FERMR <br />