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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS E^X�PPIyR�E�S�1 YEAR FROM DATE ISSUED <br /> .JOB ADDRESS 1'7(Pr7-- 17163 BeFDQdLy RdJ CrTY/ZIP 11 {. /► 5-3 r// m <br /> CROSS STREET �ur1,1 ASU ,5 1 t APN •^"'�-rWPAR EOL Sar I'I� LAND USE APPLICATION0 <br /> OWNER NAME uun+our1 -(�JS� ��)��G �) PHONE 'I w <br /> OWNER ADDRESS '^ N/^�,. hS�e rIp�M�] ^ �Ir�Ie - • CI STATEILP �^4arn NoLy e. 45381 <br /> CONTRACTOR �r 1 V Y O �� rlZR/-f 7C(J PHONE1 <br /> CONTRACTOR ADDRESS 17a�9 &1�n W04ly Prey CITYISTATEMP LANE{''`,, <br /> rr'P Cr) 954p33/y,0 <br /> a Etc <br /> SUBCONTRACTOR GEPl_ pal r/ON P14OONE 9/6- °7 9 9 rl l/U <br /> SUBCONTRACTOR <br /> ADDRESS CrTY/STATE/ZIP `>I x0 N, <br /> LICENSE 1-1557 C-61 D-09 Olhef NUMBER5y <br /> 9fZ4"7 ExPIRATioNDATE <br /> DOMESTIC WELL SAMPuNc: General Mineral/Coliform Bacteria(4391)::Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesbcfPdvate -Irrigation/Agricultural " Industrial -Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner- Water System Name Contac Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well _ Well Aheration/Modification Other <br /> i.:Monitoring Well(s) #of wells Soil Boring(s) 3 a o1 bonne° Geotechnical a of boring, <br /> C Out-Of-Service Well - Out-Ol-Service Well Renewal Cross-Connection Repair <br /> New Pum .. Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method i.1 Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth (00 it Excavation ,.5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel - Plastic - Stainless Steel Other <br /> Grout Sed Depth 0001 ft )(Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped :Free Fall 11elother Retardant/Accelerator(name) <br /> PEDESTAL Instafled By Driller :,Pump Contractor Other <br /> Concrete Pedestal-'.Dimensions:Width ft Length ft Thick in ChristyBox C Stovepipe <br /> PUMP -. Submersible. Turbine Other HP Pump Set ft Standing Water Level fl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCAT10N 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 /> WORKE � PENSATION LAWS. <br /> MINIMU 48 HOUR AD E OTICE REQUIRED FORK INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNE TITLE / "�'L`�* N DATE / <br /> PA y4f, <br /> 2019 <br /> NFANV/RONINC V <br /> O O <br /> TN pFPq��lv�Y <br /> D FLT ENT US'00ot O Y <br /> Application Accepted By ate � Area Employee IDA' <br /> Grout Inspection By Date PECIAL Woil Permit <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth tt <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info cosh emitted Date Servic uest# Invoice III Well IDN <br /> EHD e3-J5 re.nea xrNi+e � ^�� /��/ WELL/PUMP PERMn <br />