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WELL/PUMP PERMIT <br />SAN JOAOUIN COUNT/ ENVIRONMENTAL HEALTH NPARTMENT 1868 EAST HAZELTON AvENUE-STOCKTON CA 95205.6232 (209) 4684420 <br />NON-REFUNDABLE PERMIT WWW.S oV.o� /@hd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CRY%ZJP a.` <br />ROSS STREET APN ARCEL SIZE ZILAND USE <br />APUCAnON <br />JWNER NAME PHONE�-�# <br />� <br />)WNER ADDRESS /lAr7VI / (1') A/,n ,, . <br />— . <br />_ Al___�' III• - <br />PHONE <br />SUBCONT7FtTY:C- <br />IC ADDRESS <br />C A P <br />LICENSE57❑ C-61 0.09 U Other NUMBER (�/ /f/J�'_`-*' CxPiRAT10N DATEBILLING P ❑ DINNER C CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL S PLING: U General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />IERMr-OUBE DomestlQ`Privdte 0Irrigation <br />/Agriwltural Industrial WaterqualltyMonitoring G SoilSampfing/Character¢adon <br />ubllc Water System <br />It dNHirant from Owner. water System Name <br />Contact Nuns or Phane Number <br />TYPE OFWORK New Well Replacement Well We8 Alteratlon/Modifikagon <br />Other <br />7 Monitoring Well(s) # of wells a Soil Borings) a of boring' ❑ Geotechnical A or boA�s <br />Out-OfyVep Out-OfService Well Renewal Cross.Connedon Re <br />New Pi—o..�.., pelf <br />Drilling Method - Mud Rotary '.: Air Rotary <br />Proposed Well Depth ft EAuger = Ceble Tool Push Point Other <br />Excavation in diameter _. Open Bottom C Gravel PaddGravel Size <br />Conductor Casing In diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter_ in ThidmesS/Geuge/ASTMSchad <br />Grout Seat Depth Steel Plastic Steel = Other <br />P 11 -_ Neat Cement (94 Ib bag/5-10 gal water) -1 Sand Cement <br />Senlonite (20% solids) -� Other sack mixt) gal water <br />Grout Placement Method "D Pumped - Free Fag = Other L Retardant/Accelerator (name) <br />EDESTAL Installed By Driller ' Pump Contractor - Other <br />Concrete Pedestal GDimensions: Width ft Length ft Thick in = Christy Box = Stove Pi e <br />EuxeSubmersible^_ Turbine Other HP Pump Sal fl Standing Water Level <br />It <br />1 HEREBY CER IFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE <br />WORK WITH SAN <br />ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED UCENSE IS <br />CURREN N,1D LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />tS CO�JIPENSATIgt�L AVS_—� <br />A <br />; F' � CALL DATEDVI9 /110VO <br />ECEjejq <br />VIED <br />r 8 2®21 <br />gQU1N CO <br />DeAL <br />?0ApAR �EN7Tl' <br />rA MENT U E NLY <br />Application Accepted By Dale i.) Area Employee ID#; <br />Grout Inspection By 1 f Dale SPE AL Well Permit <br />Pump Inspection By ` t. Date J <br />—1lG�L� WAIVER R@C@iV@d <br />COMMENTS <br />Sog Boring Inspectton By 1 Date Constructed Well Depth ft <br />WELL IPULIP PERMr <br />