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WELL/PUMP PERMIT >r, <br /> SAN JOAQUIN C.0,44fI&VIRONMENTAL HEALTH DEPARTMENT 1868 EAST 14AZELTON AVENUE-STOCKTON CA 992175 f 49)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS ��1� ',� — � �[✓� `, >,.w ri to <br /> �" F'i'r-`. t ---L r/�P�"�--"fic•�a .. CrrylZi,'P iC <br /> CROSS STREET, APN �y.�;r ARCEL SIZE L/, '�LICATION# I p <br /> OWNER NAME <br /> PHONES;)""", -�..��r�T y <br /> OWNER ADDRESS �,.$',�, 1� ""d.� C STATEI7SP _- <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS 'J ,er,�q <br /> '.`,_�✓�)—5 ,✓�1 CITY1STATFJZIP__.� I[� e/q .. <br /> SUBCONTRACTOR J'"�"Jy ¢yI,xPHONE_ <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE -57 OC-61 [3D-09 ❑Omer _ _— NuMSER 4y,��- ExPIRA-noN DATE. <br /> DOMESTIC WELL SAMPUNG:ElGeneral Mineral/Coliform Bacteria(4391)[]Dibromochforopropane(4392)[]Arsenio(4393} <br /> INTENDED USE mestiG'Prfvate ❑lmgationlAgrlcUft ral ❑industrial ty g ❑Soil Sampiing/CharacWrization <br /> ❑WaterOuali Montorin <br /> 3 Public Water System <br /> If dMem tt from Owner "4Pere7"5'yS£erci Name` <br /> .____`."Cor�i.aoTMa`me or Ph`orr`Nivn"S`ar - <br /> TYPE Or WORK 3New Well F.]Replacement Well ❑Well Atteration[Modification (,']Other <br /> QMonitorin9Weir(s)—.—#OfWelIS ❑Soil Bon natboings yofbemo <br /> []Geotechnical <br /> ❑Out-Of-Service Well ❑Out-OfService Well Renewal []Cross-Connection Repair — <br /> 71New Pump Q,Puml?Replacement_,...UPUM2 Repair CTION JQRaise Well Casing <br /> WEtL CONSTRU <br /> Drilling Meth"ud Rotary ❑Ax Rotary []Auger ❑Cable Tont 0Push Point ❑ Other <br /> Proposed Well Depth 24 .ft ExcavationZ in diameter <br /> ---LC1 Open Bottom <br /> E] 38ravel Pack/Gravel Size_ �in diameter <br /> Conductor Casing in diameter 1 Contluctor Casing Depth ft <br /> Well Casing Diameter in Th' n S GaugeIASTMSched ❑Steel QStainlessSteel <br /> --__ ]Plastc []Other-- <br /> t Grout Seat Neat Cement(94 111 bag,5-f0 gal water) and Lament -7 r--� <br /> o l r_ —, -S sack m rl7 gal water <br /> tb ❑Bentonite{2t)losalids) QOiher <br /> Gro P erttMethod []Pumped ❑Free Fal! []Omer ❑RetardantlAcce}erator{name)._-- <br /> PE_DESTAL Installed By 00riiiar Ump Contractor. ❑ Other ----�-----.._..---- <br /> []Concrete Pedestal mansions:Width ft Length ft Thick n QCfiristy Box []Stove Pipe <br /> PUMP ubmersible�Tur#>ine [•;)Other -�y�.; <br /> HP� Pump Set ft Standing Water Level -��' <br /> 1 HEREBY C RT'IFY THAT 1 HAVE PREPARED THIS APPLICATION ANp THAT TME WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUlN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTNE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINI R E NOTICE RE4UiRED FOR INSPECTIONS- LEASE CALL{209)697, <br /> TITLE DATE L ( <br /> I <br /> I <br /> I <br /> I I <br /> DEPARTME T U E ✓p <br /> n» Itr,�j!Jr? ,✓:�pted8y r w,- no - ,._1_. Aran <br /> Grout Inspection By �m- Date l7 <br /> Pump inspection By I © SPECIAL Well Permit <br /> _ Date D WAIVER Received <br /> Soil Boring Inspect" $y Date. Constructed Well Depth <br /> COMMENTS n/ <br /> _. <br /> PE 5C Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date $etVlCe R oast# Invoice# Well ID# <br /> e -h <br /> ILL <br /> EHD 43-06 8.8)1116 <br /> WELL lPUW PERMIT <br />