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PHONE <br />ate <br />Date <br /> D Z7117:-2,i <br />Date <br />C-61 0-09 <br />OWNER <br />LICENSE -57 <br />BILLING PARTY: <br />Other <br />NUMBER <br />CONTRACTOR <br />SUBCONTRACTOFt/CONSULTANT <br />PHONE <br />EXPIRATION DATE 6/7'3/410 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br /> <br />CITY/STATE/ZIP <br /> <br />Water System Name It different horn Owner. anted Name or Phone Number <br />Domesnc WELL SAMPLING: General Mineral/Goliform Bacteria (4391) - Dibromochloropropane (4392) - Arsenic (4393) <br />JNTENDED USE mestic./Private Irrigation/Agricultural Industrial Water Quality Montoting Soil Sampling/Characterization <br />Public Water System <br />Well Alteration/Modification Other <br />Soil Boring(s) Cot bonngs Geotechnical lot bonngs <br />Out-Of-Service Weil Renewal Cross-Connection Repair <br />Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary Auger <br />Proposed Well Depth ft Excavation <br />Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel <br />Grout Seal Depth It Neat Cement (94 lb bag/3-10 gal water) <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fat Other Retardant / Accelerator (name) <br />Installed By Dnller Pump Contractor Other <br />Concrete Pedestal 'Dimensions. Width ft Length ft Thick in Christy Box Stove Pipe <br />sack mod7 gal water <br />Cable Tool • Push Point Other <br /> in diameter Open Bottom Gravel Pack/Gravel Size <br />ft <br />Plastic Stainless Steel Other <br />Sand Cement <br />TYPE OP WORK New Well Replacement Well <br />Monitoring Well(s) 0 of wells <br />Out-Of-Service Well <br />New Pump "aump Replacement <br />WELL CONSTitucnom <br />!PEDESTAL <br />in diameter <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 85206 4232 (209)458-3420 <br />NON-REFUNDABLE PERMIT WWW.S • ov.or ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />,D.)-) AX 4'( rc, PLA. Ctry/DP <br /> <br />tO <br /> <br />5 JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />s Io <br /> APH q6,0, ID <br />3"-e fc:4= ‘111c-La +01(11 <br />OWNER ADDRESS /r9•03 /711060,ii 0.-/evA6 <br />Kr'17 ress• Pairtp rv; ( e <br />CONTRACTOR ADDRESS 3E) 3 Ai • L.4 Vie (At, kalL <br />CONTRACTOR <br />LAND USE APPLICATION <br />CITY/STATE/LP <br />PHONE pit <br />- st <br />PARCEL SIZE <br />CRY/STATE/LP <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Sod Boring Inspection By <br />COMMENTS <br />-6r9d' T TLE__ej4)1k-t4Q— DATE <br />11/211NIAVIT <br />kriEPARTMENT USE ONLY <br />Date 4) //././ Area 44/1e;e Employee ID* DA <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />Pump VS6ubmersible Turbine Other HP Zi Pump Set/V_ It Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR ILL BE DONE IN ACCORDANCE ITH 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 />WORI(EBSCOMPENSAT1ON LAWS , <br />M 48 HOU PJIJ VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953- 697 <br />SIGNED / 041-1-, <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />- , <br />Check*/ <br />Cash <br />Amount <br />Remitted Date PermIU <br />kemie• Request I/ Invoice * Well IN <br />Li •L k 1 0 L- - /0 11i,._- 4 7 7 101‘112-6. Wi'00i-12-V i-1 S <br />For 41.09 <br />WELL IPLINP PERMIT