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INTENDED USE Xomestic/Pnvate Irrigation/Agncultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />: Public Water System <br />it SIlerent from Owner Water System Name ContAct Nacre or Phone Number <br />TYPE OF WORK XNew Well Replacement Well = Well AlterationllYlodification O <br />beeves <br /> <br />of twinc. <br />t e <br />Monitorirtg Well(s) 0 of wells r: Soil Boring(s) <br />Out-Of-Service Well I. Out-Of-Service Well Renewal <br />New Pump LI Pump Replacement : Pump Repair <br />WELL CONSTRUCHON <br />Drilling Method )( Murl Rotary LI Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth SCA) ft Excavation in diameter Open Bottom 7 Gravel Pack/Gravel Size in diameter <br />Conduccir Casing in diameter I Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth fl I. Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixl7 gal water <br />fvBentonite 120% solids) Li. Other <br />Grout Placement Method ...Pumped Free Fall Other Retardant / Accelerator (name) <br />EgsigEr_ Installed By Driller II Pump Contractor Other <br />Concrete Pedestal Dimensions: VOdth It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set It 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 COMPENSATION LAWS. <br />Vlsitki 48 HOURtAICE OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Dr- ()-4 DATE 471,01 SIGNED <br />.7 Geotechnical <br />Cross-Connection Repair <br />Raise Well Casing <br />....I 1/4) - • <br />Soil Boringrpectio By <br />COMMENTS <br />‘ AR/MENT U E <br />Application Accepted By re _Date <br />Grout Inspection By <br />Pump Inspection By <br />Date <br />Date <br />rD Constructed Well Depth ft <br />o ce197-10 <br />Employee 111)9 akl Ay <br />SPECIAL. Well Permit <br />WAIVER Received <br />C <br />WELL/PUMP PERMIT <br />p z r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT AL 09)953- <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR i70; (V-vs \.„,Lt. by, k mn <br />CONTRACTOR ADDRESS <br /> 114-14 <br />1868 EAST HAZY:170N AVENUE - STOCKTON CA 95205 - (209) 468-1420 <br />7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Lken <br />LAND USE APPLICATIO <br />;eal) ioNE3etis 7„3,, -u( I <br />Orr/Sun/Le • L SICk-( <br />PHONE ,Q.C4 .61W4T72 <br />crros-rAlvzip Rtv\if tort rk IL IC 14 <br />CITY/ZIP <br />SUBCONTRACTOR <br /> <br />PHONE <br />SUBCONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br />LICENSE )(C-57 . C-61 D-09 Other NUMBER 1.- <br />4, )L4c1-3 EXPIRATION DATE <br />DOMESTIC WELL SAMPUNG: General MineraVColiform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />PE <br />Codes <br />SC <br />IRfo <br />Received c — <br />,ip <br />Amount Permit/ <br />Service Request 0 Invoice I Via 100 <br />/ PO ii, g • <br />RReod r <br />l ..))5CC\ <br />1 <br />pit <br />14 i PO <br />AC ----- <br />, <br />TI-0 434/9 re,ua I/ 1418 WELL /PUMP PERMIT