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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PE <br />/R <br />tMIT ^ WtNW.s ov.or lend EXPIRES <br />I YEAR FROM DATE ISSUED <br />JOB ADDRESS 1-11 1 ��s.p�j�u k�1% �� - ` 1Q �%` CITYIZIP dtoc 1 Vrl U? O5 <br />CROSS STREET—C �lFC+t a M AP/Ny . - �1��.�,,1� <1eO/�V7YARCEL SIZE -_kAND USE APPLICATION # <br />OWNER NAME Volaz "Qk�V{� TV1V�C�t�,1[{VyL� LL,/ �,,PPH�ONE /AWA <br />OWNER ADDRESS/ (� j r, ` {/,�,('� t,"l {�' ��f wp 04 _ CITY/STATEIZIP t y en( l (B 9s <br />CONTRACTOR ` A- w2 ZJY 1, `1r Ll� rPHHO.NIE 9S f7- r_Q <br />' CONTRACTOR ADDRESS Itt�;jj I/�� �i� Q1L`r� jCITYISTATEIZIP CILI � CA C(S(0V <br />SUBCONTRACTORICONSULTANT Kl CLkq L.Q�ti1n I , ' a, u ` k,k ' , `PHHO`NE c Ca,&I 2t 4���3/4 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1 0 .7 RAAAn1Ij Iri6d W ITY/STA�TE/IZ��IP_ 4L"�'tr� (J al 0 CA ItYiO"{� <br />LICENSE VC -57 ❑ C-61 D-09 _: Other ` NUMBER-.r_L EXPIRATION DATE '411.1202Z <br />BILLING PARTY: D OWNER _, CONTRACTOR .! JUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) D DibrotTiochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domeslic/Private 0 Irrigation/Agricultural _, Industrial !' Water Quality Monitoring 1_ Soil SampUng/Characterization <br />Public Water System <br />U rStrerenl rrom 0v Water System Name Contact Name or phone Number <br />TYPE OF WORK O New Well Replacement Well 5 Well Alteratmn/Modirication 7 Other <br />O MonitoringWell(s) # of wells i Soil Boring(s) s not Iwrings not borings <br />9() Geotechnical _ <br />Out -Of -Service Well -i Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump C Pump Replacement D Pump Repair I Raise Wen Casino <br />Drilling Method - Mud Rotary Air Rotary /Auger r! Cable Tool Push Point Other <br />Proposed Well Depth5-1 it Excavation (_ in diameter C Open Bottom Gravel Pack/Gravel Size in diameter <br />F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel D Plastic C Stainless Steel Other <br />Grout Seal DepthSSR _A 'Heat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mixA gal water <br />Bentonite (20% solids) 7 Other <br />Grout Placement Method 0 Pumped Free Fall 'Otheralar n ccelerat r (name) <br />PEDESTAL Installed By _ Driller 7 Pump Contractor Other <br />C Concrete Pedestal 1 -Dimensions: Width ft Length ft Thick In D Christy Box ^ Stove Pipe <br />PUMP C Submersible Turbine ❑ Other HP Pump Set ft Standing Water Level (1 <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 V41TH THE CAL)FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />DEPARTMENT USE NLY ` <br />Application Accepted By !/ � Date a4�.s a� I Arra Jt' fan Employee 101 /775 <br />Grout Inspection By Dale i SPECIAL Well Permit <br />Pump Inspection By A w % A Date I 1 WAIVER Received <br />Soil Boring I.n��'�cUon B 6'��r�—f r Date lS/ k r � Constructed Well Depth ft <br />AMENTS /1�f17iS �Y/1�I1 .�r7Ci n,F Ln VvFflbLl-�n`74 6rlf'Aot�.rrl.;I r-+ed� Fla:r, I,Js�t�l�1/�07% <br />PE <br />Codes <br />SC I Received Check#/ <br />Info 8 Cash <br />Amount PenniU Invoice # <br />Remitted ervlce a uest # <br />Well ID# <br />72 <br />ISO I <br />00 <br />EK0 43-06 BI11P-e 19 h4 /f ry' / / n ^ /1 ^ e d 1 � �n 1 l� 117 `yT�L IPU6fP EERNIT <br />VVVIII IJ.r ) r.lt y11 y `/ 1 4 � ✓ �v�(/� <br />