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r WELL/PUMP PERMIT <br />1�011N-R <br />JOA IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-7420 <br />UNDABLE ERMIITT/� /J �n n WW/W�.s. ov.orlehd EXPIRES 1 YEAR FROM DATE ISSUED <br />OB ADDR SS _ ,5t3 / Y-�nLXX .(//!� CITY/ZIP <br />AEET / /,1014 APN OL / V7 - <br />CONTnnCTOn Aooncoc <br />SUBCONTRACTORIC ONSULT <br />CEL SIZE / _LAND USE APPLICATION 4 <br />PHONE <br />C'ITY/STATEIZIP5VYJ� LJ4 <br />�PHONEUL%/_� 2/ �1../y?L/lJ��-O/yLLD <br />PHONE <br />'TRACTORICONSULTANT ADDRESS / / '7 �y� rj—( CITYISTATEI7J4L1f j /i[KZiU LI <br />VC -57 L C-61 D 0-09 Li Other NUMBER 'AM14_5` EXPIRATION DATE I 3/ -tel <br />PARTY: tJ OWNER U CONTRACTOR LI SUBCONTRACTOR/CONSULTANT <br />DOMESTTC WELL SAMPLING: [ I General Mineral/Coliform Bacteria (4391) 11 Dibromochloropropane (4392): ! Arsenic (4393) <br />.NTENDED USE omestic/Pdvate [l Irrigation/Agricultural it Industrial c Water Quality Monitoring '.I Soil Sampling/Characterization <br />D Public Water System •"-1 <br />If diferent from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well I:! Replacement Well it Well Alteration/Modification Other <br />+ U Monitoring Well(s) # of wells D Soil Boring(s) 9 of borings U Geolechnical At of borings <br />U Out -Of -Service Well U Out -Of -Service Well Renewal 7 Cross Connection Repair <br />Drilling Method 'XMud Rotary rj Air Rotary U Auger 0 Cable Tool 0 Push Point U Other <br />I-ruposeu Well Liepul a 60 it txcavauun -�_)_ In Giameter a vpen eouunl X caravel vaclobravei a¢e In Diameter <br />❑ Conductor � Casing in diameter / Conductor Casing Depth If <br />7 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched CO D Steel 'APlaslic C Stainless Steel to Other <br />Grout Seal Depth J00 If ❑ Neat Cement (94 lb bag/5-10 gat Water) D Sand Cement sack mixt! gal Water <br />G Bentonite (20% solids) D Other <br />Grout Placement Method 1Pumped D Free Fall D Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By U Driller Pump Contractor D Other <br />D Concrete Pedestal ❑Dimensions: Width L6— It Length ft Thick in P Christy Box D Stove Pipe <br />Pump ! Submersible❑ Turbine U Other HP Pump Set If Standing Water Level <br />I HEREBY CERTO THAT 1 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 COMPENSATI LAWS. <br />MINIMUM OUR ADV C� OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED > �-� � /, — TITLE �' �/ T I/t�iL7 DATE <br />MEMEN _:::: <br />:::: :::::: MMM M::C:::M::::::6:SC■::::: a • <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />• • lit ' ' • <br />E140,13de 6/1117014 WELL !PUMP PERMIT <br />