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WF <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 I IPUMP PERMIT <br />NON-REFUNDABLE PERMIT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - <br />CALL (209) 953-7697 FOR INSPEC (209) 466)420 <br />TIONS E <br />JOB ADDRESS 5 �jj, ���eh <br />XPIRES 1 YEAR FROM DATE ISSUED <br />� 1 -Int ' 1 <br />1 CITY/ZIP— <br />CROSS STREET Qyrv-y` �\wy- APN Z-9- I q(j - 310 PARCEL SIZE 3, 3t'iN�LAND USE APPLICATION <br />OWNER NAME T�lr'p I r!A <br />OWNER ADDRESS <br />L- PHONE 32.1 - (M 611.1 <br />J S3S� (,fit. 6{q �Lll+t <br />CITY/STATE/ZIP r LL 9 S <br />CONTRACTOR MA3rIt, -1 DriIIIMI TA <br />,t PHONE 52-Z — 1 az-s <br />CONTRACTOR ADDRESS I In 1� 16e 6e S <br />CITYlSTATE?JP-,Mpd CQ qns, <br />SUBCONTRACTOR <br />CITY/STATEr7JP <br />SUBCONTRACTOR ADDRESS <br />LICENSE )(C-57 D C-61 11 D-09 D <br />PHONE <br />NUMBER �k---z— EXPIRATION_..._ <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391),*,Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private it Irrigation/Agricultural fi Industrial _I Water Quality Monitoring D Soil Sampling/Characterization <br />❑ Public Water System <br />II different from Owner Water System Name <br />Contxl Name o Phone N be <br />TYPE OF WORK New Well ,. Replacement Well D Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells D Soil Boring(s) n of borings D Geotechnical a of borings <br />I _ Out -Of -Service Well D Out -Of -Service Well Renewal r 1 r.. ------- :-- ---- <br />Well Casinn r <br />Drilling Method X Mud Rotary i. Air Rotary ❑ Auger C Cable Tool C Push Point ❑ Other <br />Proposed Well Depth%ID tt Excavation W <br />in diameter G Open Bottom Gravel Pack/Gravel Size _ in diameter <br />F Conductor i9sing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter n Thickness/Gauge/ASTM Sched 2.010 U Steel )IPlastic <br />Grout Seal De ❑Stainless Steel i Other <br />Depth P It i� Neat Cement (94 Ib b8915-10 gal water) -.i Sand Cement sack mix/7 gal water <br />xbentonite (20% solids) E Other <br />Grout Placement Method Pumped Free Fall ❑ Other C Retardant / Accelerator (name) <br />PEDESTAL Installed Py - Driller F. Pump Contractor 0 Other <br />Concrete Pedestal Dimensions Width It Length It Thick in El Christy Box 1.1 Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set It Standing Water Level <br />ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAIS <br />N <br />REQUIRED <br />FY <br />CURRENT AND ACTIVE ORDINANCES, <br />THESTATE <br />REGULATIONS.JOAQUIN COUNTY LAWS, AND RULES AND <br />CAL FORNIA CONTRACTORS STATELICENSE BOARD AND T HI T I AMT INYCOMPLIANCE IWI HS ALL <br />wnRKERS COMPENSATION LAWS. , I►IcoGrTIOIVS - PLEASE CALL (209) 953-7697 t <br />rn <br />D <br />a <br />N <br />/Area L.- 1 Date g - e" Employee ID# <br />Application Accepted By / e Date Ll SPECIAL Well Permit <br />Grout Inspection By rl WAIVER Received <br />Dale <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS P- ,41 <br />Q�El QED <br />902 ?021 <br />ONMEcoUNTY <br />DEPARTMENT <br />ft 1 r <br />