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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />YEAR FROM DATE ISSUED <br />NON-REFUNDABLE PERMIT Litk \ LL titial VUJ , Ve r.an, ....F. .-.............. ____ <br />i 1 i i 4 CrrriZip ISCAIIMIZIAA ---_, lag , ,„,,,. JOB ADDRESS <br />1 r 'APN 205 /7 0 - ?g0 PARCEL SQE LAND USE APPLICATION # <br />CROSS STREET t i ..11 <br />MOilk Mint:44V —plitil OWNER MIME illMN fraNZ-141/ PRoNE 20q-§e15- 948. <br />2D I rn waif gat crryisTATEmeatalorsi, GA 6153z0 <br />OWNER ADDRESS 21) <br />MASVIIS Print NJ MO PHONE 221C1 ' 911. gat <br />CONTRACTOR q <br /> <br />filmrs ra. CITY/STATE/ZIP MONA/ Gof .192)97 <br />CONTRACTOR ADDRESS lig <br />PHONE <br />SUBCONTRACTOR <br />CITY/STATE/ZIP <br />SUBCONTRACTOR ADDRESS <br />Num.e.t011$1022 EXPIRATION DATE 04 - 30'94)24 <br />LICENSE %C-57 0 C-61 0 D-09 o Other <br />Arsenic <br />DOMESTIC WELL SAsteLING:')f General Mineral/Caform Bacteria (4391)X Dibromochloropropane (4392) 0 (4393) <br />JorrEnoeo 1.151 'Domestic/Private 0 Irrigation/Agricultural 0 Industrial E Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner Water System Name Contact Narne or Phone Number <br />0 Other <br />TYPE OF WORK tew Well XReplacement Well 0 Well Alteration/Modification <br />*of borings e of borings <br />" Well(s) C of wells 0 Soil Boring(s) 0 Geotechnical <br />O Monitoring <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL ConaradcTion <br />Tool 0 Push Point 0 Other <br />Drilling Method y Mud Rotary 0 Air Rotary 0 Auger 0 Cable <br />in diameter 0 Open Bottom 0 Gravel Pack/Gravel Sizeir IP in diameter <br />Proposed Well Depth V1)0 ft Excavation ____ <br />in diameter / Conductor Casing Depth ft <br />0 Conducti.r Casing <br />PS 2.00 0 Steel X Plastic 0 Stainless Steel ci Other <br />Well Casing Diameter in Thic.kness/Gauge/ASTM Schad <br />PO I lb bagi5-10 water) 0 Sand Cement sack ralxfl gal water <br />Grout Seal Depth ft 0 Neat Cement (94 gal <br />Other )1/4Ientonite (20% solids) 0 <br />Grout Placement Method% Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor CI Other <br />ft Thick in 5 Christy Box 3 Stove Pipe <br />0 Concrete Pedestal °Dimensions: Width ft Length <br />Egle 0 Submersible 0 Turbine 0 Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR NOTICE REQUIRED FOR,INSPE p/,,,,k1410E <br />WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />I ALSO CERTIFY THAT MY REQUIRED IJCENSE IS <br />BOARD AND THAT I AM IN COMPUANCE WITH ALL <br />TIONS - PLEASE CALL (209) 953-7697 <br />TITLE DYIMY INNt17- DATE <br />SIGNED <br />2 1 dts. .g <br />y <br />1 1 of <br />) I2- 09S1 lOrlq .' too*, tkA1.101 ILL - <br />DEPARTMENT USE ONLY <br />Application Accepted By•----'------Ii/-:--iff--" Date I°' d / <br /> <br />Grout Inspection By ,5 6'0'A/4 <br /> <br />Date —2-1 <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring InApeOal By Date <br /> <br />t,- j • I I I, , . . _ -.1 -tt._ <br />COMMENTS 1-4 l_rptve., tr• pi, -Ai> pf-- l' ,-• , / <br />PE <br />Codes <br />SC <br />Info <br />Received Clivackl/ Amount <br />Remitted Date Permit/ <br />!vice R • mist # Invoice 0 Well ID* <br />L / iiti jicsi41-- Pi) ,' /*tt li 'OD 41 14 ki <br />//, / L A: ....4--- f i SO i 0 <br />.-13Cio2 ' 1 17/,,i t -4-4Z t V <br />Area / Employee ID# <br /> <br />C, #4- <br />tt <br />o SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Wellpipth ft <br />/2-15S6q/ WELL RUMP PERMIT EHO 4506 5,01/16