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WELL/PUMP PERMIT ' <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE - STOCKTON CA 95206-6232 (209) 468-3420 <br />DATEISSUED <br />JOB ADDRESS Zy//�,///�' �� CITY/Zip _Qi(A-4go <br />CROSS STREET J,"llf:/HCl Pf^^✓ APN - I�LJ V 3D PARCEL SIZE 13�' " LAND USE APPLICATION # <br />OWNER NAME T�z "�1' PHONE <br />,,/ 9.75 683 `ef"5? <br />OWNER ADDRESS �%�%�y� ��%J/�/b ..y� CITY/STATE/ZIP Al-41—rtc0� �/� 0'r,* 0,0 <br />CONTRACTOR ' 1 e /��%r/��w2t 'WC, PHONE ?D' 772 - A7T 7 <br />CONTRACTOR ADDRESS _ ,ap4}+i AIW, '? /Ppb CITYISTATE/ZIP <br />SUBCONTRACTOR/CONSULTANT PHONE <br />LICENSE ;11' C-57 <br />BILLING PARTY: <br />ADDRESS CITY/STATE/ZIP <br />0 C-61 , i D-09 I Other NUMBER 1&7107e EXPIRATION DATE O -•;/-ak1ZZ <br />OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING:XGeneral MineraMoliform Bacteria (439 1) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE 7DDomeslic/Private Irrigation/Agricultural r Industrial Water Quality Monitoring �i Soil Sampling/Characterization <br />o Public Water System <br />If different from Owner Water System Name Conrad Name m Pt c Number <br />TYPE OF WORK n New Well JOReplacement Well I/ Well Alteralion/Modifiration n Other <br />II Monitoring Wells) #of wells I Soil Boring(s) #nlbanap r Geotechnical #ol bnnngs <br />a Out -Of -Service Well Out -Of -Service Well Renewal D Cross -Connection Repair <br />^_ � New Pump U Pump Replacement Pump Repair l I Raise Well Casing <br />Drilling Method jQ Mud Rotary o Air Rotary I I Auger f Cable Tool i Push Point ; i Other <br />Proposed Well Depth jf07W It Excavation /?!& in diameter I i Open Bottom At Gravel Pack/Gravel Size in diamelE <br />I., Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter Ihickness/Gauge/ASTM Sched ?tie 21 a Steel APlastic rI Stainless Steel I I Other <br />Grout Seal Depth It ❑ Neat Cement (94 lb bag/5- 10 gat water) Ix Sand Cement /d• 3 sack mix17 gal wale <br />I Bentonite (20% solids) ! i Other <br />Grout Placement Method V Pumped 0 Free Fall ll Other C i Retardant / Accelerator Inarnel <br />PEDESTAL Installed By A Driller : i Pump Contractor n Other <br />U Concrete Pedestal t101mensions Width �. ft Length r 0 Thick (`_ in U Christy Box D Stove Pipe <br />PUMP AlSubmersible0_Turbine n Other HP _V Pump Seto_ It Standing Water Level R <br />I HEREBY CERTIFY THAT I 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 />�p DEPARTMENT U E ONLY <br />Application Accepted By _ / ��_ Dates N .7) Area Employee ID#g� <br />Grout Inspection By :/� _ Date Z SPECIAL Well Permit <br />Pump Inspection By AhftArAtDate AT- $'- Z L ,k WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTSEX1� +4 a ID be rs�%si <br />PE <br />Sc Receive <br />Chec #/ Amount <br />ParmlV <br />Codes <br />Into y <br />a Remitted <br />D to <br />Invoice # Well ID# <br />Service Request # <br />g190 <br />0s;7 <br />Igc�._ <br />21 <br />3 <br />bio <br />a <br />;_�Z <br />_U00694 <br />439 ► <br />►� <br />a <br />EHD43A0 6111/1019 WELL/PUMP PERMIT <br />'A <br />D <br />o: <br />