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WELLIPUMP PERMIT <br />SAN JOAOuw Cou TY EuvotommENTAL HEALTH DEPARiwqir 1965 EAST HAZELTON AVENUE - STOCKTON CA 95203 - (209) 4/E-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADOREss '201 135 CITYMr i iAll1Y., C4 <br />CRoseSTREET 19mul P& AM 20-7-29O-qoo PARCEL SIZEZ.Oin LARD USE AvxicATONs <br />OWNERNANIE MolStS f,si 1 PHONE io4q' 5893 <br />owwR ADDREss 21115 {.AMC 1 KL U. CrTYISTATE/LP KI LAA P. 9.30 <br />CONTRACTOR t 11 / r 11 1R NC- PHONE 52-Z- 1'12-9 <br />CONTRACTOR ADDRESS 111 N(bfls crrr/STATemP Wbdtsto' et yS:�s% <br />SUBCONTRACTOR PHONE <br />,SUBCONTRACTOR ADDRESS CTTY/STATEMP <br />LICENSE JkC-57 O C-61 U D4)9 0 Otter NmNm b6f*2i Exp -A— DATE q- 340"V <br />DorEsm Vku SAnPLm: N General Minemi/Coliform Bacteria (4391),] Dibromochloropropane (4392) o Arsenic (4393) <br />WT04M USE 0 InigationlApEiadhral 0 Industdal 0 Water Quality Monitoring 0 Sal Sampling/Charaderfzefion <br />❑ Public water System <br />H aswwr tom Ow vverw Bymm Nwm Caret Nwne a Ph— NanEw <br />TYPE OF WORK )e New Well Replacernent Well 0 Wes AftrMonlModihcation ❑ Other <br />❑ Monitoring Well(s) 0 of weal D Sol Boring(s) • a ourp 0 <br />0 Out -0f -Service Wes ❑ Out4X-Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Msdwd XMud Rotary U Air Rotary 0 Auger 0 Cade Tod 0 Push Poled D Other <br />Proposed wen Deph-2L,0—ft Excavation 12— in diameter ❑ Open Bottom XGlavel Pack/Gravel S' Z in diameter <br />0 Conductor Cesip in diameter / CwAkx;t r Casing Depth It <br />Wen Casing Diameter _J._ in Thickness lapdASTM Sdred ZC - 0 Steel 01 Plastic n Stainless Steel 0 Other <br />Grout Seal Depth LOV it 0 Neet Cement (94 B bag,5-10 gal water) 0 Sand Cement sack morn gal water <br />>4%nronke (20% solids) ❑ other <br />Grout Placement Method A Pumped 0 Free Fag Cl Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller Pump Contractor 0 Other <br />❑ Const@Psdesbl ❑Dimensions: Width ft Length ft Truck in ❑ Ctw" Box 0 Stow Pipe <br />pM 0 SubmersideO Turbine 0 Other HP Pump Set ft Standing Water Level ft <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />"UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SKINED Trite :j'w� DATE 9 - S' 2-/ <br />FNT <br />vi © <br />1/v CO <br />�,ENTq Nry <br />QRrMFNr <br />DEPARTMENT USE ONLY <br />Application Accepted By � - Date u? ' " Ates < C Employee IDK 7 <br />Grout Inspection By Date Z1 2 ❑ SPECIAL Well PeITnit <br />Pump Inspection By Deb ❑ WAIVER Received�7 <br />Sol Boring Inspecson,By Dals Comtrueled WN19eplh 2 I J ft <br />��7•7/1%/�■IhG�F3�7�iifJ�,/ ri'i�11.�11d�91���1�� <br />E3O 43MaouEe I,32 F73 �i 7 <br />