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WELLIPLIMP PERNNT <br /> SAN jOAQUIN COUNTY EWPONMENTAL HEALTH E)EPARTMENT 1I 8681EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-34.2-3 <br /> NON-REFUNDA5LE PERMIT www..- EXPIRES I YEAR FROM DATE ISSUED <br /> Job ADDRESS <br /> J <br /> '�',z <br /> C-ROSS APN V7 6-7 b I ..Z__L/kND USE PLICATION# V <br /> (�_Vie_[of <br /> N E R N/,M8_: Ptofwlfle <br /> OWNER ADDRESS t 601 C-Myl,A-11M (-p <br /> -1 -7- 1A,Y-<Cf C1 '03 <br /> �CONTRACTOR P ONE <br /> I CONTRACTOR ADDRESS "Mq 5 317 <br /> 1 SUBCONTRACTOR/CONSULTANT �� iONE A <br /> I <br /> SUSCONTRACTORICONSULTANT ADDRESS QTYSTATE21P <br /> f <br /> E,<PIRA'T1OI9 DATE <br /> -61 D­09 h.e i, U 24 <br /> LICENsE C-57 C� <br /> 81LUNG PAR--y: OWNER CGMTRACTOR SUBCONTFZACT0RJC0NSU0'ANT <br /> DONIES-,IC WEL SAMPLING: _Genpral Kneral/Coliform Bacieri-:&14391) -_ Dibrornechloropropane(41392)_-,Arsenic(4393) <br /> INTENDED USE Domestic/Private - Irrigation/Agricultural - Industrial - Water Quality Monitoring - SoiiSampling/Charact-aezL4tior1 <br /> - Public Water System <br /> It different from Owner Water System Name Name or Phone Nutrue, <br /> RK - New Well Replacement Well Well Alteration/Niocifflication Other <br /> of bc-ringsof borings <br /> - Monitoring Well(s) #of walls 7 Sol!Boring(s) GeotechniC jA' <br /> �'* <br /> - Out-Of-Service Well Renewal Cross-Connection Rep /V'r <br /> Out-Of-Service W I =Balsa Well Casin" ':IV <br /> New PumpRump Replacement Pump Repair <br /> LJ'L1E_LLCON3TRU TION <br /> OCT30 2nv <br /> Drilling Method - Mud Rotary - Air Rotary - Auger Cable Too! Push Point Othe, <br /> z in diameter) <br /> Proposed Well Depth Excavation in diameter Open Bottom '_ Gravel a IN-( <br /> UN4j&VTj�/V7'y <br /> Conductor Casing—, in diameter Conductor Casino "M L <br /> 11 Grout Seal Depth tt. Neat Cement(94 lb bagl,5-10 ge!waled Sand sack mix17 gal water; <br /> 1 Well Casing Diameter —in Thickness/Gauge/ASTM Schec� Steel Plastic Staid-ss St Hil <br /> Bentonite(20%solids) = Other— <br /> i3rout P(acernerit Method " Pum.ped - Free Fall Other Retard?.qt.'Acceieiator(name) <br /> ;REDESTAL Installed By = D-,-Iller Pump Contractor Other <br /> Concrete n <br /> Pedestal Dimensions:Width ft Length ft Thick Christy Box St via Ti <br /> =j <br /> submersible- Turbine - 0--her_ HP Standir)b 'aiate. -eve <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCIJPDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS.. AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE. WITH THE CSUFORNIA COf RACTof�,�S STATE LICENSE BOARD AND THAT F AMI IN COMPLIANCE WITH ALL <br /> VV)RIKERS SAF N LAWS, <br /> MINI U HOUR 0 i ME-Q U i 1-1,E DEECIA PLEASE CALL P109 <br /> SIGNED ITLE :AA A <br /> Ul- <br /> -4- <br /> A <br /> --L <br /> -�-�-� t- - <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 101d91,30;0 Area e Employee ID# FR <br /> Grout Inspection By Date D SPECIAL Well Permit <br /> Pump Inspection By Date (I( ' (V-Jy ! I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received heck#[ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By --Cl-sh Remitted Service Request# <br /> 0570 .3 97 C7_7 _V11,40 VIQNIMQ::� <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />