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WELUPUMP PERMIT <br /> SAN JOAGuvt CoutrrY EwfRoow ENTAL HEALTH DEPARTMENT 1868 EAsT HAzELTON AvENUE-STOCKTc#i CA 95205-(209)4683420 <br /> NON-REFUNDARI E PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADoREss ,$22 7 6 re-t I c— cmrzs R'1 ioo11 <br /> CRoss STREET LTV&K h f r APIN J 06 V s� PARCEL SIM_LAim USE APPUcATxm a o� <br /> Ovntiur NAAw H1� Dau"As G n PHONE 204-(ovs-b 13 O <br /> OwNEt AnoREss 1I. )G'l l r. 5 ;t CTTy/STATdzP ' <br /> CONTRAROIt <br /> CoNTRACToRAooREss 4905 t CrTY/STATEIZlP k11�/e `rl� 9S, C, <br /> SUSCONTRACTOR PHONE 20q in W D g - Z OG 4 <br /> SuaccmTRAcTOR ADDRESS_ CTfY/STATE/Ze' <br /> LICENSE '=C-57 SrCF>7 _=D-09 _Other NtrsER ZV Z 7� ExrlrutwN DATE 9-36'010 z( <br /> DOMESTIC WELL SAMPLING:E General MmeraKol"rfoirn Bacteria(4391) Dibrornochloropropane(4392)L Arsenic(4393) <br /> ll.T%ND..u­ Le6sticzPrtvate _1-gatgNAgrlttAtteal Industrial t:Vlydter Quality Moratonng J Sod Sampling/Charactenzation <br /> G Public Water System <br /> tf d4fereet Eom 0 r er. Wafer Sysim Naim Cerdad Name or Ph.—N—d— <br /> TYPE OF WORK + 4W Well Replacement Well Well AltereborJModdcation C Other <br /> C Monitoring Welgs) t of wells Sal Borings) °f°o"'� Geotechnical s or bm gs <br /> Out-Of-Service Well Out-Or-Service Well Renewal =Cross-Connection Repair <br /> L-New Purnp C Pump Replacement u Pump Repair 2 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C MW Rotary :i Au Rotary C Auger =Cable Tool G Push Point 7 Other <br /> Proposed Well Depth ft Excavation_ in diameter -1 Open Bottom -_Gravel Pack/Gravel Size in diameter <br /> Conductor Casing_ in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter__in Thickness/Gauge/ASTM Scheid ^..Steel 'Plastic _Stainless Steel Other <br /> Grout Seal Depth ft =Neat Cement(94 Ib bag/5-10 gal water) r Sand Cement sad*mix(T gal water <br /> Bentonite(20%solids) --Other <br /> Grout Placement Method ::Pumped =Free Fall C Other :Retardant I Accelerator(name) <br /> PEDESTAL Installed By -_Driller '-:Pump Contractor F Other 'e R. <br /> C Concrete Pedestal:Dimensions'Width ft len <br /> gdt R Thick m �_Christy Box C Stove Pipe <br /> pyo ubmersibleC Turbine C Other HP /1 Pump Se1141ft Standing Water Leve4 R <br /> I HEREBY CERTIFY THAT I 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 /> 'It .r9UN14S t - L'DANCE NO;EGA REQUiRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SI%� T. Corillm aa- 0"-t 2 DATE-30--ZO Z' <br /> IL I <br /> FCS FSI T <br /> u IVF <br /> (� A N <br /> w 1. V41COUNTY <br /> RTIyENT <br /> DEPARTMENT USE ONNy Le,Y <br /> Application Accepted By � Dalo ' OsV Area `1`� Employee IDB <br /> Grout Inspection By { Date ❑ SPECIAL Well Permit <br /> Pump Inspection ey C L,•+Lt f r y L,.rr`.:. Date l-L)21 L;bi. ❑ WAIVER Received <br /> Sal Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS i•-)(:I *t-,2 "11;r vel 'Z/vAtJt,�,C�c: L i <br /> PE SC Received Check#/ AmountDatePermit! Invoiced We11 IDN <br /> Codes Into cash Rertodled Sernfe Requests <br /> Is`o2 ? <br /> EHD 4306 I.A d411VIS WELL 1PUNP PFAMIT <br />