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WELUPUMP PERMIT <br />SAN JDAdmN Coutm E1MRdNMENTAL HEALTH DEPARTMENT 1966 EAST HAZELTON AUME • STOCKTON CA 95205 4232 1209) 460-3420 <br />Joe AOOREsa ViJ3-9999"5 Austin Rd CrrY p MW40W 95376 <br />CROSS STREET Arch Rd APN20106005 /�1,16- <br />PARcs S - LAW USE..ATtoN 9 <br />OWNER NAME �'- , 6,4 Fd f :,-j4l - 1 n G PHONE 209.2359622 <br />Z �r <br />OWNER ADDREa11B <br />e .Rd. P U r,a LI J- CmA,:�96»� A13TATEZP <br />CONTRACTOR Ouesla Engineering C.orpon $on PHONE 516-236.6114 end. 212 <br />CONTRACTOR ADDRESS 1220 Bridaysrd Cow Rd Ste 206 Cm/STATaIbP RidwTwnd( CA/94501 <br />SuecoNraACToR/CoNauLTAHT Goo -Ex Subsurface Explosion PHONE 916-261.3529 <br />:TORfCONSULTANTADDREss <br />VC -57 0 C-61 0 DA9 <br />n: 0 OmMut <br />Crrr/STATLMP D4on. CA, 95620 <br />0 Other NUMBER 954217 ExPIRAnow DATE 07/31/22 <br />BCONTRACTOR 0 &wcowTRACToR1CoNeuLTAMr <br />Doaeaflc WELL SAMPLING: O General MlneraKollorm Bacteria (4391) L Dibromochicropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Inigetlon/AgrkuNural C Industrial 0 Water Oudty Monitoring QSoll Sampling/CharaclerizNbn <br />0 Pubic Water System <br />IraN.r.Mk-0..1.1 WY.r STM—N— C.rMd A. wPh.-Nu.b.r <br />TYPE OF WORK 0 New Wag 0 Replacement WON 0 Wes Aleration/Mod6caion 0 Dow <br />0 Monitoring Wal(s) 9 of vela 0 Sol Boring(:) a or boergs ,dGeolechrdul 2 e of bmiap. <br />0 Out -Of SeMce Well U OuWf-Service Well Renewal 0 Cmas•Connecdon Repak <br />U neW <br />sling Method W Mud Rotary 0 Air Rotary W Auger 0 Cade Tool 0 Push Point 0 Other <br />'oposed Well Depth BD/ 100 R Excavation _ 6 In dameter 0 Open Bottom 0 Gravel Pack/Gravel Size In dameW <br />0 Conductor CnNg k1 dlanteter I Conductor Casing Depth R <br />Well Casing Diameter _ In TldckneselGauge/ASTM Schad O Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth 60/ 100 N 0 Nast Cement (94 ro bag,' -10 gal water) 0 Sand Cement sack nvz(7 gal water <br />0 Bentonite (20% Solids) 0 Other <br />rout Placement Method dPumped C Free Fal 0 Other 0 Retardant / Accelerator (name) <br />P'QgyAL installed By 0 Driier 0 Pump Contractor 7 Ottwr <br />0 Concrete Pedestal ODimenslons: Vsldlh R Lerplh R Thick In 0 Chrbty Box 0 $tow Pipe <br />PUMI. 0 Submersible Turbine 0 Other HP Pump R Standing Water Level fl <br />I HEREBY CERTIFY THAT 1 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, 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE HATH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AN IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SASHEDM11 M M 48 <br />rLiH�DV tE NQ=E REQUIRED EFOR INSP€ClIp S -PLEASE CALL _ 7 L <br />RF yMF <br />cF��NT <br />rtia1'1R j O��Ty <br />MFNT <br />DEPARTMENT USE NLY <br />Application Accepted By 4/i Dale 3 3J Area Employee 109 A <br />Grout Inspection By -'x Date r v' 0 SPECIAL Well Permit <br />Pump Inspection By Date 0 WAIVER Received <br />SW Baring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />M" �� ®® <br />®ter AAZnom r_Tw:mElm�■M-EXA �E:9..■��■ <br />EHO 4}50 W V401e WELL fi-t W FERMn <br />