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r )OMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) G Arsenic (4393) NTENDED USE ❑ DomesWPrivate Inigation/Agdcultural D Industrial ❑ Water Quality Monitoring Fl Soil SamplinglCharacterization 0 Public Water System h dfMetW Ban Owner; Water System Name Contact Name or Ph— Number rYPE OF WORK XNew Well D Replacement Well O Wen Alteration/Modincabon D Other 0 Monitoring Well(s) # of wells 0 Soil Boring(s) ❑ Geotechnical ` C Out -Of -Service Wen D Out4X-Service Well Renewal C Cross -Connection Repair n o....... P—ir D Raise Well Casing Drilling Method ❑ Mud �RatslI�y ❑ Air Rotary ❑ Auger OlCable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation — in diameter ❑ Open Bottom [.Gravel PacklGravel Size n diameter ❑ Conduct Casing in dierneter / Conductor Casingepth ft Well Casing Diameter in Thickne0 Nest Come M Schad � q Steel ❑Plastic O Stai e s Steel i_. Other �j $and Cement—sack mixfJ gal water Grout Seal Depth R ❑Neat Cement (44 Ib baggy 10 gal water) `j` 0 Bentonite (20% Solids) ❑ Other p Retardant / Accelerator (name) Grout Placement Mth eod Pumped D Free Fall ❑Other PEDESTAL Installed By D Drilbr 0 Pump Contractor ❑ Other ft Thick in ❑ Christy Box ❑Stove Pipe ❑ Concrete Pedestal DDimensions: Width ft Length PVMP ❑ Submerslble0 Turbine ❑Other Hp Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WTTH SAN ND RULES AND REGULATIONS. I ALSO JOAQUNCURREINTCAND ORDINANCES THESTATE LAWS, ACALIFORNIA CONTRACTORS STATE LICENSE BOARD ANDRTHIAT I AM N CO PLIANCEFY THAT MY REQUIRED IWI HS ALL DEPAHIMcn. •• _ ApplicationL L Date Accepted BY ------ �� Grout inspection By Date Pump Inspection BY Date �— Sod Bodng Ins JOdiprl By Date COMMENTS FU.,.+ l Area ',� tr Employee IDS l ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth R E WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE - STOCKTON CA NON-REFUNDABLE PERMIT 95205 - (209) 4583420 CALL 209 953-7697 FOR INSPECTIONS PIRES I YEAR FROM DATE ISSUED JOB ADDRESS /NE� (X Cn-yZP UlL I tit LlW 4 CROSS STREET APNPARCEL SIZE LAND USE A/P�PUCATION OWNER NAME a m PHONE �l �/' OWNER ADDRESS CITY/STATE/LPI-ry, �"J�j1; CONTRACTOR V1l N CONTRACTOR ADDRESS 1 PHONE CITYI$TATEILP—Mo SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CIT'/STATEZP LICENSE C-57 ❑ C31 ❑ D-09 ❑ Other NUMBS 2Z EXPIRATION DATE )OMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) G Arsenic (4393) NTENDED USE ❑ DomesWPrivate Inigation/Agdcultural D Industrial ❑ Water Quality Monitoring Fl Soil SamplinglCharacterization 0 Public Water System h dfMetW Ban Owner; Water System Name Contact Name or Ph— Number rYPE OF WORK XNew Well D Replacement Well O Wen Alteration/Modincabon D Other 0 Monitoring Well(s) # of wells 0 Soil Boring(s) ❑ Geotechnical ` C Out -Of -Service Wen D Out4X-Service Well Renewal C Cross -Connection Repair n o....... P—ir D Raise Well Casing Drilling Method ❑ Mud �RatslI�y ❑ Air Rotary ❑ Auger OlCable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation — in diameter ❑ Open Bottom [.Gravel PacklGravel Size n diameter ❑ Conduct Casing in dierneter / Conductor Casingepth ft Well Casing Diameter in Thickne0 Nest Come M Schad � q Steel ❑Plastic O Stai e s Steel i_. Other �j $and Cement—sack mixfJ gal water Grout Seal Depth R ❑Neat Cement (44 Ib baggy 10 gal water) `j` 0 Bentonite (20% Solids) ❑ Other p Retardant / Accelerator (name) Grout Placement Mth eod Pumped D Free Fall ❑Other PEDESTAL Installed By D Drilbr 0 Pump Contractor ❑ Other ft Thick in ❑ Christy Box ❑Stove Pipe ❑ Concrete Pedestal DDimensions: Width ft Length PVMP ❑ Submerslble0 Turbine ❑Other Hp Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WTTH SAN ND RULES AND REGULATIONS. I ALSO JOAQUNCURREINTCAND ORDINANCES THESTATE LAWS, ACALIFORNIA CONTRACTORS STATE LICENSE BOARD ANDRTHIAT I AM N CO PLIANCEFY THAT MY REQUIRED IWI HS ALL DEPAHIMcn. •• _ ApplicationL L Date Accepted BY ------ �� Grout inspection By Date Pump Inspection BY Date �— Sod Bodng Ins JOdiprl By Date COMMENTS FU.,.+ l Area ',� tr Employee IDS l ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth R E