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1 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-5420 <br />NON-REFUNDABLE PERMIT CALL ZU9 953-7697 FOR INSPECTIONS rr��EXPIIRES 1 YEAR <br />/AIFROM <br />CLIAATE ISSUED <br />,JOB ADDRESS / ) � O ci,aIP GSCQ�of, i CA L73W <br />CROSS STREEI_�_ {k� 10 h1t%ti���- 1A�PN L).)S0`yl3 —PARCEL SIZE S•(� LAND USE APPLICATION ri <br />OWNER NAME 911f "bA RIA Yt L.k 1 PHONE /',t <br />OWNER ADDRESS L234% MG$nd� KL) CITYISTATE2IP VSCiw�a CA 5-5-3W. <br />CONTRACTOR A mini ✓1 ,O 1 nAPHONE 7-09.-7 ( 15 • (P2_7(o <br />CONTRACTOR ADDRESS r 510 t) SG �iG Or't P �/a CrTY/STATEIZIP / l[� V1�f ([� I A g 53,3 (R <br />SUBCONTRACTOR PHONE__ <br />SUBCONTRACTOR ADDRESS CITY/STATEMP 8 c Z <br />LICENSE I I C-57 C-61 I' D-09 i i Other NUMBER � ExPIRATION DATE. 3( Zo <br />DoMEsTic WELL SAMPLING: ! General MineraUColiform Bacteria (4391) I Dibromochloropropane (4392) i Arsenic (4393) <br />WENDED USE : DomesticJPrivate Kirrigation/Agncultural � Industrial . Water Quality Monitoring : Soil Sampling/Cnaractenzation <br />Public Wafer System <br />It 11".—I fir— 0vm W °lar Synlnm Nom° Co 1-t Nance cr PI -1. 1h 1 - <br />TYPE OF WORK I New Well i, Replacement Well i Well Alteration/Modification I I Other <br />I Monitoring Wells) # of wells t Soil Bonng(s) a ai Dations : Geotechnical <br />Cut -Of -Service Well I i Oul-Of-Service Well Renewal Cross -Connection Repair <br />lSCNew PumD Pump Replacement I Pump Repair I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ! Air Rotary ; Auger i, Cable Tool I Push Point I Other <br />Proposed Well Depth_P, Excavation in diameter i I Open Bottom i Gravel Pack/Gravel Size in diameter <br />I Conductor Casing In diameter / Conductor Casing Depth it <br />Well Casing Diameter l^— in Thickness/GaugelASTM Sched ! Steel ,(Plastic Stainless Steel Other <br />Grout Seal Depth fl I I Neat Cement (94 /b bag/S10 gal water) I Sand Cement sack mfxr7 gal water <br />r Banionile (2O% solids) i I Other <br />Grout Placement Method Pumped ; Free Fall ! Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller I I Pump Contractor : Other — <br />- Concrete Pedestal I Dimensions: Width it Length R Thick in Christy Box Stove Pipe <br />Pune Submersibles I Turbine : I Other HPPump Set It Slanding 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 rALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMP AT OJT S. <br />MINI 1 /VANCE NOTICE REQUIRED FOR (INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED.._ ✓1 I L� TITLE �'/'C�r''E%vr^ DATE <br />1 2_d <br />Checkti! <br />Cash <br />Amount Date Permit, Invoice # Well ID# <br />Remitted Service Reguas # <br />/ <br />ApplicalienAccepted By '—`/"--' <br />DEPARTMENTONLY <br />Dale / / ),;,D <br />I <br />Area y �3�r U��Employee ID#_F� <br />Grout Inspection By / <br />Pump Inspection By <br />Dale (� <br />Dale '[ L <br />I SPECIAL Well Permit <br />I WAIVER Received <br />Soil Boring inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth ft <br />loZo,tq <br />Q01jV <br />FP EV r4Z <br />4r <br />PE Sc Received <br />Codes Info By_ <br />Checkti! <br />Cash <br />Amount Date Permit, Invoice # Well ID# <br />Remitted Service Reguas # <br />EMO 4:-06 /wltcE."i's TELL/'VIP PERMIT <br />�Slc� �ll�sSz�� D <br />