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SKWED TITLE, DATE , <br />Employe. lop <br />PECIAL Won Permit <br />WAIVER Received <br />Constructed Well Depth <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPAATAENT 113S8 EAST HAZELTON AVENUE. STOCKTON CA 95205 4232 (209)4684420 <br />i NON-REFUNDABLE PERMIT i /3 -7 4 4 www.sigov.orgfehd EXPIRES 1 YEAR FROM DATE ISSUED ;JOS ADDRESS 1 All F, Az. ,,,p1 ,I, ,,-<• <br /> <br /> cmazip F.1,-.4,16 A ... ch, /S..5.zo <br />:CROSS STREET A vc4u. t_ct , APN 2-1_3 - 13 0- °5- PARCEL SIZEK 93LANO USE APt PuCATION 4 ' <br />OWNER NAVE <br />!OWNER ADDRESS 1 2, 7 2. 7 rk Are k l <br />•iz:41. <br />CONTRACTOR /43R Efs e e"-- <br />CM/STATE/ZIP 6‘ 6 AL 4` n q 5 3 2-0 <br /> PHONE <br />; CONTRACTOR ADDRESS .14;1 `.)1 'Ai' t.Pe .51x,..e(. ,i+;,6 crryrswiTerzin P2:sz3inex.i. /.4- C? 3-P"2- <br />< SUBCONTRACTOR/CONSULTANT •-•,' rt43 1,7' (!ryite:(N a, i ,er, C • PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS If::`,A 9 IV' TPL 415(64 CITY(STATPJZIP rr`L°5i1 0 i 13 f•I`2"' <br />Lemse e; C47 C-61 0-CS Other Rumen 32_0_124ApboRATfOrf DATE 3-31-2022 <br />BILUNO PARTY: — OWNER PICONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC Well SmtPuiva: General Mineral/Conform Bacteria (4391) Dibromochloropropane (4392) • Arsenic (4393) haehoco use . Domestic'Priyate IrrigationiAgncoltvral Industrial Water Quality Monitoring . Soil SamMingiOnaraFtertzetion <br />Public Water System <br />it povehi. EOM Oares, Kiser System Name Comac Npne or Prone Number <br />TYPE Or Woes Now Well Replacement Weil Wet AlteratiOniMOdification Other <br />Monitonnp Welts) 5 of vreSs XSoil Bonnp,(s) 3 s, o, yrtaga X Geotechnical 3 Out-Of-Sereite Wet Out-Of-Seruice Well Renewal Cross-Connection. Repair New POMO Pump Replacement P.m(' Repair Raise Well Casing !WELL CONSTRUC,TION <br />iDrIlling Method Mutt Rotary Air Rotary X Ap2er Cable Tool Pusn Point Other <br />!Proposed Well Depth ft Excavation in diameter • Open Bottom Gravel PackeGrayel Size at diameter , Conductor Casing et diameter t Conductor Casing Depth ft <br />Wet Casino Diameter .__ in ThicknessiGairortASTM Sched Steel Plastic, Stainess Steel Other Grout Seal Depth It Neat Cement (94 lb ce5i5-10 goi wager-) <br />SEl!DA itE (20% solKisi Other <br />Grout Placement Method Fumeed )( Free Fall Other _ Retardant / Accelerator (name) _ <br />PEDESTAL Installed By Driller Pump Contractor alter concrete Pedestal Dimensions • Width t Length ,t Thick In Christy Box . Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing water LeYel ft ! <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 WORKERS COM5ENSATION LAWS. <br />MINIMUM 413 itOuR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7597 <br />4 ('‘ y Nora <br />Sand Cement sack mixIT oat water <br />ck. <br />1 <br />Application Accepted By <br />Croat Inspection Ei <br />Pump Inspection <br />Sail ?Spring Inepettion By <br />COMMENTS <br />DEPATIiENT US 0 LY <br />a ( 1-5 -1 <br />Date <br />Olim_W-1P/ZVJ <br />et <br />It <br />. Amount 1 .. <br />Codes <br /> treef.eiyannau ,.. %..... <br />REMi ad Date I Permit( <br />ko R Invoice a Siv ice e <br /> <br />fri Th , Well 105 . <br />--MN 1 ' nnt) 4 1..Ck,Q_L____ ...f <br />wEll !RCMP PERMIT