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LkJ <br />,50 <br />WELL/PUMP PERMIT <br />SAN JOAOUDI Colmar ExinnotatorrAL HEALTH DEPARTMENT 1868 am- HAZELTON AVENUE - STOCKTON CA 95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERhirr wWW-sjgOv.o4ahd EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS fioei 9 i- 5ou+1, ictvi A IZ.4 cirez,p 1h 19-4 i---?-6#9 9, 3) <br /> RCEL SIZE LAND USE AeeuCATioN I* <br />.'' 40 <br />CROSS STREEr Pl'e< 0 rr APN PA ' <br />MA11- LL) t_t; - I it_ <br />OWNER ArmilEss nlv Crry/S-rxrelza, <br />Corriruscrott liCMC\ S Lr'\d‘PA Now <br />COMI-RACTOR ADDREss crrwsrATErzip <br />SUBcONTRACToR/CousuLTANT <br /> <br />PHONE <br /> <br />SIRICONTRACTOR/ConSuLTANT ADnREcs LITT/STATE/ZIP <br /> <br />LICENSE ,._ C-57 /C-61 19-09 L! Other Nuusta 741S EXPIRATION DATE 'V .- 4,s' /— <br />BALING PARTY: OWNER C CoNTRAcTOR : SuBCONTRACTOPJCOKSULTAMT <br />OWNER NAME p„opiE zo9-42.7? <br />DOMESTIC WELL S.SiG! •J General fiAineraUColiform Bacteria (4391) i Dibromochlor pane (4392) _ Arsenic (4393) <br />INTENDED USE KDomestic/Private 7 Irrigation/Agricultural L Industrial C Water Duality Monitoring C Sol Sampling/Characterization <br />fl Public Water System If diftereol earn Owner. <br />TYPE OF WORK olw Well I I Replacement Well , Well Alteration/Modification Other <br />WELL CONSTRu <br />1, Monitoring Well(s) a of wells Soil Boring(s) 4 of bar Gentechnical of 15orin <br />Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair New • I Pump Replacement ' ' Pump Repair : Raise Well Casing <br />Drilling Method I i Mud Rotary . Air Rotary 1 Auger I : Cable Toot • i Push Point I i Other <br />Proposed Well Depth_ ft Excavation in diameter = Open Bottom 2 Gravel Pack/Gravel Size in diametia- <br /> <br />C: Conductor Casing in diameter / Conductor Casing Depm ft Well Casing Diameter in Thickness/Gauge/ASIM Sched _ Steel C Plastic il, Stainleec Steel : Other Grout Seal Depth ft 7 Neat Cement (94 lb bag/5-10 gal water) n Sand Cement iiiiack mix/7 gal water i I Bentonite (20% solids) ' Other <br />Grout Placement Method : Pumped C 1-re::....13....-- : Other. _I Retardant / Accelerator (name) <br />Water System Nava Contact Nama cr Phone Number <br />Installed By C Driller Pump Contractor Other I I Ceiate Pedestal I Dimensions- Width , ft Length in I • Christy Box I Stove Pipe <br />ubmersibleC Turbine 11 Other HP Pump Setif.X.2- ft Standing Water Level <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED UCENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS_ <br />PEDESTAL <br />R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TrriE(yrei DAI-E -42 <br />, <br /> PARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By Date <br />PumD InsPection BY 'WWI \Ci C.StiviA Date <br />Soil Boring Inspection By Data COMMENTS rJe I rim -4 J n0140 : • '7 <br />Date vaaii Area Employee 164 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />sc <br />Info <br />Recerv.d Checkli <br />... Cash <br />Amount <br />Remitted Date / 1 <br />Permit/ <br />Service Request # Invoice,/ Well ID, <br />Li36/0 0..-1 <br />, <br />ti (s_ .,13-..Z I I 29/4 4k) piptvivs-- <br />1/2 2 1 <br />tie <br />,._„....,.... _........„.. ,. _ • Com WILL /PUMP PERMIT