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o--- WELL/PUMP PERMIT <br />SAN JOAWIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468.3420 <br />NON-REFUNDABLE PERMIT <br />oV.cr lGhd hXPIRES 1 YEAR FROM DATE ISSUES <br />S s r+ <br />JOB ADDRESS fj i� <br />,tom Awww.s <br />7 leAr/ CIT'ILP�[� ,ZJ` <br />ter} <br />CROSS STREET V!// r <br />7 p <br />/DI / PARCrE�L SIZE/ LAND US£APP�LyIGATIOyN�)# <br />ti//�MtiPN <br />OWNER NAME I✓�If-+-�'Ya/moi <br />� /b <br />�- tf/(i {V_'JZ AG„C-T PHONE ! I <br />OWNER ADDREHs/�f� <br />7YY^I�` <br />CrrytSTATayIZ�I,P�� � 421-y iS6� <br />CONTRACTOR %1L///.ir <br />.r yr <br />ZF'ze,P-HH0N"E_��1� <br />CONTNACTOR ADDRESS ;2 ,�jll� <br />f��ac- /�� CITYISTATEIZIP ��,f�1> Z� <br />SUBCONTRACTORICONSULTANT //(I_.�IIL,I� <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS <br />( CITYISTATEMP <br />LICENSE CkP57 001 00-09 <br />0 Other UMBER EXPIRATION DATE <br />BILLING PARTY: 0 OWNER <br />0 CONTRACTOR D SUacoNTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: xGeneral Mineral/Coliform Bacteria (4391) kDlbromochloropropene (4392) D Arsen)c (4393) <br />INTENDED USE Domestic/Private 0 IrrlgallordAgricuttural 0 Industrial U Water Quality Monitoring D Sotl Sampling/Characterization <br />0 Public Water System <br />If olnerenl from Ov cr.. Wafer system Nemo Confavt Name or Phone NurMer <br />TYPE OP WORK O New Web AV Replacement Well 0 Well Alteration/Modificatlon 0 Other <br />O MDnitDeMg Welt(S) #Of Willis 0 Solt Boring(s) a°t bo fps U Geotechnica( 4ofb rinpe <br />0�" /Out -Of -Service Well 0 Out -Of -Service Well Renewal O Cross -Connection Repair <br />k+New Pump 0 Pump Reolecemenl O Purro Repair O Raise Well Casino <br />Drilling Method OJAud Ratery 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth _�R ' Excavation f — In eflameter 0 Open Bottom ravel PaeklGraval S,ze 4V In diameter <br />D Conductor Casing in diameter I Conductor Casing Depth R <br />Well Casing Diameter _[2 in Thickness/Gauge/ASTM Schad I Steel VPlastlr O Stainless Sleel D Other <br />Grout Seel Depth R D Neat Cement (94 Ib beg/S-10 gal water) 0 Sand Cement j sack mlx17 gal water <br />TVBentonite (20% solids) 0 Other <br />Grout Placement Method Pumped D Free Fall D Other O Retardant I Accelemtor (name) <br />PEDESTAL ' Installed By 0 Driller O Pump Contractor 0 Other <br />0 Concrete Pedestal DDlmenslons: Width R Length ft Thick In 0 Christy Box O Stove Plpe <br />Pu MP ubmersfblaD Turbine 0 Other HP Pump Set,_,_ 1? ft Standing Water Level"/ -it <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICA ION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND R ES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CO S STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. —7*S3 Pj� <br />MIN µytnI T VANCE N t (f��IR R INSPECTIONS - PLEASE CALL 209 /953 p6F <br />SIGNED �J/�js��?L� 1�V� T TRLE // AFy✓.�'( DATE /q_/7-91 <br />DEPARTMENT USE ONLY <br />Application Accepted By -� �- Date 1;UbY a3Du0 <br />Grout Inspection By <br />Pump Inspection By <br />Date <br />Dale <br />Area I' i Employee ID#DA <br />_ <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Soil Boring Inspection By Date 'Constructed Well Depth rt <br />COMMENTS 104440 rjp,0eStj1 . r rer, ;i I V. <br />cnvas•Iro 6nlrzatB WELL (PUMPPERWT <br />