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WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468-3420 NON-REFUNnAR1 F Poo.Am Drilling Method Mud Rotary C Air Rotary Auger 7 Cable Tool Push Point -, Other Proposed Well Dep(h fl Excavation in diameter _Open Bottom a Gravel Pack/Gravel Size Conductor Casing in diameter 9 In diameter / Conductor Casing Depth ft Well Casing Diameter in Thidmess/Geuge/ASTM Schad Steel � Plastic � � Stainless Steel =Other Grout Seal Depth ft Neat Cement (941b ba915-10gal water) 'i Sand Cement Bentonite (20% solids) Other sack mix17 gal water !rout Placement Method ^ Pumped = Free Fall Other Retardant/Accelerator Memel Installed By ' Driller _ Pump Contractor Other G Concrete Pedestal uDimensions: Width fl Length R Thick in - Christy Box Stove e_e submenfble^ Turbine 7 Other HP Pump Sal It Standing Water Level it 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS WORKECURRE T A D ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL RS COMPENSATION LAJNS--_ CALL (209) DATE JOA QI Z®?l HI p�NqINr� N� "MFN? cP RTMENT U E NLY _ APPlication Accepted By Dele�%� Area Employee ID#&C�r(�j//� / e Grout Inspection By Date �� OSPE W@Il Permit J"i7l�jy Pump Inspection ByT/ Date = WAIVER Received COMMENTS it Son Boring Inspection By Date Constructed Well Depth WELL /'. ❑UIP pswrr CITYM�P S>� ll� X�CI Y 1^ ( —i �1� �y CROSS STREET AP4. O 'Q PARCEL SIZE 4i- / LAND USE APPLICAiION� OWNER NAME PHONE ��' OWNER ADDRESS CRYISTATEMP / Y l� l.t^J 0/--�6p15 CONTRACTOR �( PHONER-5l 13 ( / CONTRACTOR ADDRESS �TM�A�� SUBCONTRACTOR/CONSULTANT PHON SUBCONTRACTOR/CONSULTANT ADDRESS /STATE/ZIP LICENSE IL C-57 U C-61 U D-09 U Other NUTABER EXPIRATION DATE BILLING PARTY: = OWNER '-- CONTRACTOR 9 SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAt4PLIN@: ❑ General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) ❑Arsenic INTSNOGG tree `; Domestic/Pnvate_: Irrigation/Agdwltural Industrial (4393) r Water pual(ty Monitoring G Sail SampringlCharederizatlon Public Water System It dlffarent lrom Owner. Water System Neme COM -d Name ru Phone Number TYPE OF WORK _- New Well Replacement Well _ Well AilerallOn/Modification -: Other Monitoring Well(s) # of wells ❑ Sail Bodng(s) 6 -borings ❑ Geotechnical 9 of borings Out -Of -Service Wen Out -Of -Service Well Renewal E. Cross -Connection Re air Li New Pump :r SPumo Ranlarpmenr r. D,....., P Drilling Method Mud Rotary C Air Rotary Auger 7 Cable Tool Push Point -, Other Proposed Well Dep(h fl Excavation in diameter _Open Bottom a Gravel Pack/Gravel Size Conductor Casing in diameter 9 In diameter / Conductor Casing Depth ft Well Casing Diameter in Thidmess/Geuge/ASTM Schad Steel � Plastic � � Stainless Steel =Other Grout Seal Depth ft Neat Cement (941b ba915-10gal water) 'i Sand Cement Bentonite (20% solids) Other sack mix17 gal water !rout Placement Method ^ Pumped = Free Fall Other Retardant/Accelerator Memel Installed By ' Driller _ Pump Contractor Other G Concrete Pedestal uDimensions: Width fl Length R Thick in - Christy Box Stove e_e submenfble^ Turbine 7 Other HP Pump Sal It Standing Water Level it 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS WORKECURRE T A D ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL RS COMPENSATION LAJNS--_ CALL (209) DATE JOA QI Z®?l HI p�NqINr� N� "MFN? cP RTMENT U E NLY _ APPlication Accepted By Dele�%� Area Employee ID#&C�r(�j//� / e Grout Inspection By Date �� OSPE W@Il Permit J"i7l�jy Pump Inspection ByT/ Date = WAIVER Received COMMENTS it Son Boring Inspection By Date Constructed Well Depth WELL /'. ❑UIP pswrr