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J-K3 <br />--n;DPOC)C <br />A <br />tvt <br />Stk.- <br />1\1(A go5600 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ISAR EAST HAZELTON AVENUE -STOCortim CA 95.205 4232 (209)488-3420 <br />NON-REFUNDABLE PERMIT ww.sjgovorgIehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Jae Apbeess S-DO VA -. 4 t-LT. Ttne Re, <br />CROSS STREET fr,,t qVi'ff'r OSD \ \S 90:k APN 'K)SCA*4 C ; <br />m „"...., PIC PARCEL S(ZE‘ LAND USE APPLICATION* <br />OWNER NAME PA-cti,-iikv PNONE <br />ONNER ADORESS 30( /2--(1, CrryrSTAread Z.44_,OlaV, ,P,A ,r52,1 <br />CONTRACTOR k\ 0 ersii.ef SOO,. lit 14 SSOL‘o* PNONE r(31(ttl ltI'l - 1 0 k <br />CONTRACTOR ADDRESS CI o'a TA4.1,4,,„\ N,J.,--i CrrY/STATE/Z. 1,-GX (AS <br />NI 1( PlextE 'N. /Pr SUBCONTRACTORPCONNA.TAKT 'I' <br />SubCONTRACTORJCONSULTANT ADDRESS r-4.- rk4- Crre/STATE)Zip i‘d /4 <br />LICENSE It..C57 CB i 0.09 Otner <br /> <br />NUMBER U t; l ',,,,CIPTI EXPIRATION DATE 6-1311 20) 'I <br />Biu.nto PART-T ON5a CONTRACTOR V‘,.. SuSCONTRACTOR/CONSuLTANT <br />DOMESTIC WELL SAMPLING: .._ General MlneranobtOrrn BaCtena (4391) _ Dibromothlexopropane (4392) . Arsenic (4393} <br />!fawn) Use Domestic/Private IrrigatieniAgricultural Induetnal ' Water Quality Monttoring )1 Soil SamplingiChareoletintion <br />Public Water System <br />If dement horn Omar WNW SHOOP Nemo GOMEL %WM es Phone Number <br />TYPE OE WORK New Wee Replacement Welt Well Alteration/Modification , Other . <br />Moreton%) 'AWN* S ills Sorl Banng(s) 4 al-Nsrnas 7. CM#DDICIMICal I # al borings <br />Out-Of-ServIce Well - Dot-Of-Sennoe Well Renewal .; Cross-Connection Repair <br />New Pump ' Pump Replacement Pump Repair Raise Well Casing <br />I WELL q0NSTRUCT1014 <br />Recel 1 Drilling Method Mud Rotary Air Rotary A Auger Cable Toot Push Peril Onset <br />Proposed Well Deorh l.,) it Excavation j) in diameter Open Bottom Gravel Pack/Gravel Size „C'Enncliiimeter <br />Conductor OMNI in diameter 1 Conductor Comeg Depth ft e 5 <br />Well Casing Diameter in ThicknessfGaugelASTM Schad - Steel Photo Stainless Steel 00444,,Je <br />I Grout Seal Depth .4'd ft Neat Cement (94 lb da915-10 girl wale') Sand Cement 1i rTr2ikarIT .4: ..14,. <br />Bentonite (20% weds) Other TH <br />Grout Placement Method Pumped ' Free Fat Other VallATIMITEMEMEIEW111111 <br />PEDESTAL Installed By Dreier Pump Contractor Other . <br />Concrete Pedestal ,Ohnenslons: Width it Length it Thg* in Christy Box Stoes Pipe <br />Int?. Submersible, Turbirse Other HP Pump Set_ ft Standmg Water Level 11 <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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS, <br />MINIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209 953-7697 <br /> TrrtEfe,p'or$j o.44 Eper DATE <br />Application Accepted By <br />Grout inspection By <br />Pump inspection By <br />Soil Soong inspection By <br />COMMENTS <br /> Date - <br />cli:EtRIMENT U E NLY <br /> <br />Dale <br /> <br />Dale <br />Dale <br />Area_44 eitT Emptoyee <br />MALMO] Permit <br />WAIVER Rectivdd <br />Constructed Well Depth <br /> ft u/c'o <br /> <br />PE SC <br /> <br />Cod Info <br />Recetved <br />B <br />hicJt <br />Cuft <br />Amount <br />Ro Otte Parrett <br />SorVICS Restrat * Invoke # Welt Et# <br />i f a 41.+2.-, <br />ma <br />, '751 UT <br />i <br />ENO 43-00 I.11120141 Chit ,PUMPPENNIT