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WELL/PUMP PERMIT <br /> SAN JDAouIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE P�ERMIT M/WW.S OV.Or ehd EXXPIRE1S,1 YEAR FROM DATE ISSUED <br /> 1 <br /> Joe ADDRESS (� •10 3 Z(V A-�qeQ�M WN CnYZP 5 1 0 Il,l bn� q S ao a p <br /> CROSS STREET �.f JOMI► 1S `�f• ,t ApN 'XqO�O PARCEL SME I O LAND USE APPLICATION# p <br /> OWNER NAME �wppN,� � �.I Ge�r�. I 1 u 0 lI��I' q,(^ PHIS <br /> OWNER ADDRESS <br /> ONE 2 a <br /> 1e-a r-,Q)4-A Lr4 CITYISTATEMP r t O CONTRACTOR r•l/ <br /> I �1 PHONE <br /> CONTRACTOR ADDRESS 3 ao S• K r (f C h CRY/STATEMP <br /> SUSCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZCl/P y <br /> LICENSE )4C-57 C-61 D-09 Other NUMBER 434a1a UPIRATONDATE <br /> BILLING PARTY: L OWNER :.CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:Aeneral Mineral/Coliform Bacteria(4391),° Dibromochioropropane(4392)..,Arsenic(4393) <br /> INTENDED USE �Domestic/Private -,Irrigation/Agricultural .- Industrial Water Quality Monitoring -Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name V Phone Number <br /> Type OF WORK >New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wail(s) #of wells Soil Boring(s) a of bongs Geotechnical a of Donngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Vud Rotary a Air Rotary -Auger Cable Tool Push Point Other <br /> Proposed Well Depth 'yo it Excavation \\ in diameter - Open Bottom 51 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter \0 in Thickness/Gauge/ASTM Schad a*to -. Steel y,Plastic Stainless Steel - Other <br /> Grout Seal Depth 'D.0 It -341 Neat Cement(94 Ib bag/510 gal water) Sand Cement sack mix[7 gal water <br /> --Bentonite(20%solids) Other <br /> Grout Placement Method mped -- Free Fall _.Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller Pump Contractor - Other <br /> Concrete Pedestal Dimensions Width ft Length ft Thick in c Christy Box --Stove Pips <br /> PUMP _Submersible--Turbine Other HP Pump Set It Standing Water Level ft <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 48 H�E NO110E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE T {nnn!!'n'e� DATE 14-1�•' <br /> MEN 7' <br /> �QED <br /> 8262021 <br /> ONMC <br /> EOUNTy <br /> �EPgRT'WENT <br /> DEPARTMENT USE ONLY y ►y�C <br /> Application Accepted By <br /> Date Area -� �t Employee ID# r� <br /> Grout Inspection to SPECIAL W@II Permit <br /> Pump Inspection By Date ,' WAIVER Received <br /> Sol Boring In on By Date J Constructed {ell Depth _h <br /> COMMENTS W tIJ�.._ ' rl6 r inn Y1:Y��l�F �oL Uf the W8f1l1rSlYIG .�. 3 wt111L. f <br /> �� <br /> PE SC Received Check#J Amount Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Date Service Recuest#- <br /> L, ALL. �(.� LIlk I <br /> 1 (r 1W 4� <br /> c� 3 1011)0 Li I <br /> END q-OE 8/11!2019 � n � �57 9 WELL RUMP PERMIT <br />