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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 4683420 <br />NON-REFUNDABLEPew".. _ - : -- pp WWW�,,j$ lOOV-0r91ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JoBADDREe ,jrJL'LWS 4 —R 1V ,y CI Y21P �C.cc TV/) e/5ZtO 6 <br />piC,At Aa ,vl�>u,r -, I y7 <br />CROSS STREET �� /.}- c c -I�N / G'FJ D / '0 -) 1 PARCEL SIE Lt7� I. I iAND USE APPLICATION # <br />)INNER NAME (..- I r 7 O ( .7 %Zi C,--7 0 rJ 7 p <br />� <br />Zs � ASL PHONEC`Or) 93�- 7-1 <br />)INNER <br />DDZ, <br />SINNER ARESS `� D 0 "�q- Q Q s 'r <br />'ON7RALTOR TIL I - C 0 u,v TY ) CIfY{.4TATE/ZIP S G �- %O �1� c Ag s <br />// I'_)1LL.1 !j PM0NEfQQSJ6) Z'71- 00-n <br />ONTRACTOR ADDRESS 6 3 I Gia n.1 I p ST' Cm/STAM011P J�:O/fGv . C/B Cl Z/Z 6 <br />JBcoxTRAC70RlCONSUI7ANT 1 PI�}9�jC0/2/w VS{l0-v SPt4,4Ori �'fA/d) SYY, 3 Z3Z <br />ISCOlfrRACTORlCONSULTAW ADDRESS 83 / 1 V 0I" r L#4 Ho -y' Cm/�/STATFlZ?�--,���� <br />TENSE K(;-57 C-61 ^ D-09 Other NUMBER 15 � 7 / ExPiRATION DATE 30 Lr` 2 2 <br />.UNG PARTY: C OWNER O CONTRACTOR J SURCONTRACTOR/CONSULTANT <br />DoMEsTic WELL SAMPLING: C General MinerallColilorm Bacteria (4391) 0 Dibromochloropropane (4392) J Arsenic (4393) <br />INTENDED USE ' Domestic/Private n gtigetioNAgricultural C ' Industrial C Water Qual Monitorin dY g <br />Public Wafer System 7 Soil Sampling/Characterization <br />MdiHewnt from Omar. atw 3yaiam arr:e meq ame ar one um ar <br />TYPE OF WORK New Well f I Replacement Well Well Alteration/Modification ik-Other C770 rs <br />Monitoring We8(s) # of wells r Soil Boring(s) x or borings r Geotechnical s of bomrgs <br />_ Out -Of -Service Well i- Out -40f -Service Well Renewal Cross-Connectlon Repair <br />7 New Pump 7 Pump Replacement C Pump Repair C Raise Weft Casino <br />NIPr I Cn - <br />Drilling Method SMud Rotary ❑ Air Rotary C Auger G Cable Tool C Push Point iJ Other <br />Proposed Weil Depth. I C1 7- it Excavation /Z In diameter C Open Bottom C Gravel Pack/Gravel Size <br />2 Conductor Casin9 i in diameter <br />n diameter / Conductor Casing Depth if <br />Well Casing Diameter_ In Thickness/Gauge/ASTM Schell C Steel r Plastic c� mloss <br />Grout Seal Depth 00 3 Steel Other <br />P / ft C Neat Cement (94lb bagi5-!0 gal wafer) $and Cemen.` <br />'Bento_ �D�3ceck mix17 gal water <br />. nRe (20% solids) -,Other <br />]rout Placement Method /Pumped -1 Free Fall -� Other -1 Retardant / Accelerator (name) <br />]PEDESTAL Installed By d Driller C Pump Contractor ❑ Q[her <br />C Concrete Pedestal GDlmenslons: Width it Length ft Thick in cj Christy Box c Stove Pipe <br />P <br />PUMP - Submersible Turbine C Other HP Pump Set <br />H Standing Water Level R <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 t AM W COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />M�IVIMLLM 48 . HO AR'A�OTICE REQUIRED FOR INSPECTIONS PLEASE CALL (209) 953- 697 <br />SIGNED (/i� t j V ✓ T" d AF- �-*v! Ari /)l ,f 953 697 <br />a DEPARTMENT USE ONLY <br />Application Accepted By L� Date h431:,41- <br />Grout Inspection By Date <br />Pump Inspection By <br />Date <br />Soft Boring Inspection By <br />COMMENTS <br />Date <br />Data <br />Area I ,S%Ji Employee ID# As <br />❑ SPECIAL Well Permit <br />O WAIVER Received <br />Constructed Well Depth <br />.tg I Invoke A 1 Well 100 <br />EM43-0 6rr1rA19 <br />WELL RUMP PERMIT <br />127l1�3�� <br />