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Q), <br />` <br />J <br />r7 <br />S,36*""`J-06WELUPLIMP PERMIT <br />SAN JOAQUIN COUNry ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE • STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABtf PERMIT- _ - CALL (209) 90-7697FOR INSPECTIONS i . EXPIRES 1 YEAR FROM -DATE ISSUED <br />JOB ADDRESS <br />'CROSS STREET0i <br />OWNER NAME <br />OWNER ADDRESS <br />(CONTRACTOR <br />(CONTRACTOR ADORES <br />SUBCONTRACTOR <br />.SUBCONTRACTOR ADDRESS <br />,LICENSE C-57 C-61 <br />DOMESTIC WELL <br />INTENDED USE I <br />C APN Y �`fCL 5E^Y LAND l5EPP qT1 N tE�U=�(\O <br />P s P av a <br />1VW,1__ — CIN/STAT IP S U <br />PHONE IV <br />'tCIITy/S)TATE/ZIP� • v' <br />0-09 Other_ NUMBEaI) jo 1 � (/11 //'j EXPIRATION DATE <br />12 <br />General Mineral/Coliform Bacteria (4391)General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br />(4393) <br />Public Water System <br />If different from Owner: Water System Name ContaCt Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWell(s) of wells SoilBoring(s)#dbonngs Geotechnical <br />Out -Of -Service Well Out -Office Well Renewal Cross -Connection Repair <br /># of borings <br />! WELL CONSTRUCT!ON <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />I Proposed Well Depth ft Excavation n diameter Open Bottom Gravel Pack Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />'Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORD( �T�H�ECATLICIFO-RNIA <br />AWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPE A MINIMUE NOTICE REQUIRED FO(!\� INSP/Et C/tTIONSy- P/tLEAS,/E^'CALL (209) 3 66/97x^ <br />SIGNED TITLE J -e VIA / 1 ) 0 I V 1 /I Y • DATE , / 7c / / / ` <br />t<A TMENT US O�fN[�v/�Y <br />Application Accepted By 3&A-Aate 4"WZ ! Area Employee ID# <br />Grout Inspection By Date -/ SPECIAL Well Permit <br />Pump Inspection By ate �� l'j BZW WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth (t <br />COMMENTS h.®1 �`i h �An\ZI %x\ 1AJ, Q Nom_ t1 <br />',eo7-oe 3+Cine <br />WELL /PUMP PERMIT <br />19 2019 <br />N O <br />I!IM�t,rCVNTy <br />