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fl WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL I'IEALTI I DEPARTMENT 1868 EAST HA2ELTON AVENUE-STOCKTON CA 95205-6232(209)468.3420 NON-REFUNDABLE P�EyRyMIT//� www.sJqovorg/ehd ✓EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS �� dJ / 1�/f'nr'^Q rt^'t C�l,�l+ /'(��,I.,j s� �/ ! CITY2mp CROSS STREET S••'`Dt!-/T(r�`�"f Pn J &APN 2qQ U "" - 1 PARCEL SIZE I9 LAND USE APPLICATION It OWNER NAME .sItk n r (fy ��^ PHONE OWNER ADDRESS 10- Co /(_I�•I! /�/� CITYISTATE21P CONTRACTOR `1� � /�t(/{'J �(P�M�y I)�("J�y•// PAA) (�' PHON w O~ '•'��//�{l/ CONTRACTOR ADDRESS / 1r� V"� '^"��`^' `-. _ CITYISTATE2IP_,_ A SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP LICENSE G C-57 0 C-61 ❑D-09 D Other NUMBER ExPIRAnohi DATE BILLING PARTY: D OWNER 0 CONTRACTOR D SUBCONTRACTORICONSULTANT DoMEsne WELL SAMPLING:❑General MineraltColiform Bacteria(4391)D Dibromochioropropans(4392)❑Arsenic(4393) INTENOEo Us* U Domestic/Privale Irrigatlon/Agricultural 0 Industrial 0 Water Quality Monitoring D Soil Sampling/Characterization D Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK D New Well ❑Replacement Well Well AlteraUon/Modiflcation D Other 0 Monitoring Wells) #of wells O Soil Bodng(s) of borings 0 Geotechnical #otho nBa X Out-Of-Service Well Out-Of-Service Well Renewal D Cross-Connection Repair 0 New Pump_❑Pump Replacement Pump Repair D Raise Well Casing WELL CONSTRUCTION Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger U Cable Tool 0 Push Point ❑ Other Proposed Well Depth ft Excavation In diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter_In Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other Grout Seal Depth ft 0 Neat Cement(941b bao-10gal water) 0 Sand Cement sack mix/7 gal water 0 Bentonite(20%solids) 0 Other Grout Placement Method 0 Pumped 0 Free Fall D Other ❑Retardant!Accelerator(name) PEDESTAL. Installed By D Driller 0 Pump Contractor 0 Other 0 Concrete Pedestal❑Dimensions:Width_it Length ftThick in O Christy Box O Stove Pipe PUMP ❑Sul3mersibla0 Turbine 0 Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN OUNi Y ORD NCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIV TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL =_ WORKER COMPENSA LAWS. MNI U 4 UR VANCE NOTICE REQUIRED FOR INSPECTIONS•PLEASE CALL(209)953.7697 SIGNED "W N H nTLE DATE M r EI VE IIID 02020 x N COUNT N ENTAL Y p RTry1ENT �J EPARTMENT USE ONLY p Application Accepted By �+/ Date 3O 0104;k2 Area S C Employee ID# R Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boringspectien By Date Constructed Well Depth R COMMENTS r CIYt1Y1 �J O 1 ' S r-Iiitht jfjj�j) JO beC ��10✓trt� PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# hG Codes Info By Cash Remitted Service a"..UL w3 a - 779- FHD43M 6111nosg . /7/J //) O- E: � /y��n Iw��_L_ / �,^ �( �Wt lrn Pfmlrr � /-. //�5��.�b�C��-yV�r�T�� C.�/'l�,V�,-�u �d /^ ��) /i•v �- 1,�til�S r vV p'S � l I/1!m! �� '� a l'-�'�'t`r� `�� l►?�� d->�t �(.Cc-�n7�1 1♦�/�. J