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( o22ZS <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•STOCKTON CA 95205•(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> c nn ,-I �/� N <br /> JOB ADDRESS n <br /> I800� $• lbJfPG.� VN[��f CITYIzIP �t�M�"1 y53j,,(,) — D <br /> t,� a 4 so so 17 . LAND USE APPLICATION# <br /> CROSS STREET I I V'I I� APN PARCELSIZE Io SO <br /> r •��/y (� �( 7� m <br /> OWNER NAME K��e.^ U1 e�{ G� PHONE Zpq. �,toln1�I t 59SQ <br /> OWNER ADDRESS I L,ovi5e h,4e r{^ CITYISTATE/LP L5 ca.IO'\ r CA, �53Zt� <br /> COMRACTOR A �O y11 'n -1 '!� PHONE LD9.�1 !S • 10271 n <br /> CONTRACTOR ADDRESS 151 OO SG c.lc-: l2 r\P_ . CITYISTAIE(ZIP A_NI�rt^ CA 613(a <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE .I C-57 C-61 I D-09 i I Other NUMBER. 1 D`l 279(0 EXPIRATION DATE 9 3 I a <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE .1 DomeslicJPrivate O•Irrigalion/Agiicultural Industrial Water Quallty Monitoring :Sod Sampling/Charactenzanon <br /> Public Water System <br /> 11°M."M 1r Ownui. W.W.Sy:l-,Nun. eo"Idd llwn,e of Pt•nnu Number <br /> TYPE OF WORK I New Well I I Replacement Well I Well AlterationiTAodificalion I I Other <br /> I Monitoring Wells) #of Wells I Soil Boring(s) a or oonngs Geotechnical <br /> Oul-Of-Service Well ' Out-Of-Service Well Renewal I Cross-Connection Repair <br /> New Pum I'Pump Replacement Purnp Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary i I Air Rotary I Auger I Cable Tool I I Push Point i I Other <br /> Proposed Well Depth it F-xcavation in diameter I Open Bottom t I Gravel Pack/Gravel Size in diameter <br /> -Conductor Casing In diameter / Conductor Casing Depth fl <br /> Well Casing Diameler_in Thickness/Gauge/ASTM Sched I Steel Plastic I Stainless Steel Other <br /> Grout Seal Depth It I i Neel Cement(941b bagr5.10 gal walerl I Sand Cement_--_ ..sack mi;f7 gal water <br /> rl Bentonite(20%solids) :I Other -- <br /> Grout Placement Method i!Pumped Free Fail Other :I Retardant I Accelerator(name) <br /> PEDESTAL Installed By l i Drifter I Pump Contractor : Other <br /> Concrete Pedestal!(Dimensions:Width ft Length it Thick in I Christy 60R Stove Pipe <br /> t( 14 <br /> a Submersible i Turbine I I Other HP Pump Set fI Standing Water Level — it <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 COMP ISA WS. <br /> MINI 7 dM HQ R /1/ANCE NOTICE REQUIRED FOR <br /> /INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE •Y �E%L� DATE ZIP <br /> F7 III I <br /> -- - - — - — - - <br /> pA y <br /> REcF�Nr <br /> SEP ,o FD <br /> - - <br /> 2020—— - A/RON/N co <br /> I N'�A17-y <br /> i <br /> _i <br /> I <br /> & �/� DEPARTMENT US.E NLY <br /> Application Accepted 8y �/r'� Dela Area Employee ID# r r• <br /> Grout Inspection By Dale 11 SPECIAL Well Permit <br /> Pump Inspection By t''r-•��..,5 L'_ �.:'w'a•�- Dale WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS I <br /> PESC Received Check#/ Amount Dale Permit/ Invoice# Well ID# <br /> Codes Into B ash Remitted Service Re uest# <br /> DO 434e­iue Y1AnE <br />