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N'✓Vv <br />�r <br />WELLIPUP PERMIT I t, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 9520D • (209) 468-3420 <br />a <br />NON -REFUND PE M T r C <br />F <br />Received Check#/ Amount ! <br />� Cash Remitted i Date <br />! pe�� <br />Service Re ueSY <br />209 <br />9534697 FOR <br />INSPECTIONS <br />1EXPIRES <br />1 YE FRQ <br />I Su <br />terra VwkrCITY Y l t: n <br />i <br />m <br />, JOB ADDRESS P / <br />CROSS STREET V �/ / APN ofq 00 ARCEL SIZE LAND USE APPLICATION # <br />A <br />I <br />OWNER NAME "- P ONE <br />�? <br />j( <br />/T) <br />C L l <br />•({ <br />�/ '9 <br />:OWNER ADDRESS ✓ 19 CITYISTATE21P <br />�� <br />Q <br />'CONTRACTOR� _ 1 <br />HONE� <br />I <br />Q� <br />Ifyi <br />CTOq 7 <br />CONTRACTOR ADDRESS � C C � ITY/ TA P 1 l 7 J U <br />SUBCONTRACTOR V 1 PHONE/ <br />i <br />�/ <br />SUBCONTRACTOR ADDRESS r • ' CITYISTATE/ZIP / V <br />r / <br />C-$7 V C-61 D-Og Other`/ NUMBER arc �V EXPIRATION DATE <br />LICENSE <br />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391 ) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE V Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System ! <br />�" <br />If different from Owner: Water SyStem Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alterations Modification Other <br /># of borings r o` borings <br />Monitorng'.Nell(sj # of wells Soil Bering% Geotechnical <br />N <br />i <br />O - - ervice Well Out -Of -Service Wall Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Reca_ir Raise Well Casing <br />WELL C0NSTRUCTIO <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diarneter Open Bottom Gravel Pack/Gravel Size in diameter <br />�- <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />$� <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth It Neat Cement (94 /b bagl5-10 gal r atery Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in . Christy Box Stove Pipe <br />PUMP V Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />C 1 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />t� <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE 15 I <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKER SAT10N LAWS. <br />IN 24 H URA ANGE NOTI REQUIRE®i 0R SPECTiO�NSyy�-�P/LEASE CALL (209) 95 •7697AAA <br />V <br />r� <br />\ <br />SIGNED TITLE , Vt / Y �1.� DAT <br />I <br />I <br />T� <br />I <br />� <br />1 <br />I <br />i <br />J :L <br />IL <br />I'00 <br />I <br />I <br />I <br />vV' <br />P <br />If <br />�R <br />l <br />THC71 <br />Itt <br />i <br />� <br />D PARTME T�NLY� <br />A.dp7ication Accepted By Ca[' <br />Grout Inspection By Date <br />Pump Inspection By ate <br />Soil Boring Inspection By Date <br />�OkWEENTS ?J��� Vie+ tom. P l0 L qii • „r r*% <br />1 <br />y�FNT <br />CF�V�D <br />Area EmployeelD#�Ari�� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well <br />Depth <br />IV <br />PE SC <br />Codes ' Inf <br />Received Check#/ Amount ! <br />� Cash Remitted i Date <br />! pe�� <br />Service Re ueSY <br />Invoice # <br />� WeI11D# � <br />i <br />WELL iPUidP PERMIT <br />