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A <br />r� <br />ENVIRO <br />9tiLUON MLS:� LM 'cit '3;a ;WI j paAI;D;� <br />WELUPUMP (PERMIT <br />SAN JOAQUIN COUNT' ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAg1TON AVENUE -STOCKTON CA 95205 - (209) 46$-1420 <br />(VON -REFUNDABLE PERMIT CALL (209) 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3120 F M1unford ,���, c,TrlZIP Stockton 95205 <br />sTREET. _ ,, -7 r- r LY}*L(.!p APN _ l—l'I ' UU' L I 1 <br />NAM Raymond,�Paiz <br />ADDRESS 3120 E Munford�e <br />ICTOR Pur/^Box <br />Drillers, Inc <br />ICTOR ADDRESS PO U O X 6 4 <br />ICELSUE,y , LAND USE APPLICATION(( <br />PHONE 09-993-4937 <br />CI7YiS;TAT15Z,Stockton CA 952075 <br />PHONE 209-887-3554 <br />Crry/SrATT:rZmL i n d e n, CA 95236 <br />PHONE <br />SUBCONTRACTOR ADDRESS CITYISTAT E.MP <br />LICENSE G57 J C61 u D-09 U Other NUMBER E"iRATION DATE <br />DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) i rlihrmm0rhlmm�m.,�..e <br />INTENOED USE R D0mM'C1Wvate G InigatiNVAgrialltural C Industrial ❑ Water Quality Monitoring ❑ Soil SamplinglCharactenzabon <br />LI Pu ba Water system <br />RAiBe(aa; from ONr, pr, %Yater System Verne COmet1 Nm., Ph.- NunDer <br />ryPE OF WORK n New Wall r. 0 wee....,... 1e <br />�w1c„1n v.nuu—m— L laver I <br />C Monitoring Well(s) # or wells C Sal Boring(s) ° of WTI gs ❑ Geotechnical 0 Of oorinas <br />11 Out -OF -Service Well C Out -0I -Service Well Renewal D Cross -Connection Repair <br />❑ New Pumn ■ Pumn <br />IDrilling Method 0 Mud Rotary ❑ Alr Rotary -1 Auger :1 Cable Tool D Pusn Point ❑ Other <br />;Proposed Well Depth rt Excavation in diameter G Open Bottom O Gravel Pack/Gravel Size <br />in diameter <br />n Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameler _ in ThicknesslGauge(ASTM Sched D Steel D Plastic ❑ Stainless Steel D Other <br />Grout: Seal Depth It 3 Neat Cemem (941b hegv5-10 gar we" ❑ Sand Cement <br />sack mxlT gal ureter <br />❑ Bentartite (20% solids) D Outer <br />Grout Placement Method D Pumped D Free Fall D Other 7 Retardant ( Accelerator (name) <br />.PEDES"rgl installed By O Orilfel C Pump Contractor 7 Other <br />e Concrete Pedestal ❑Dimensiora: Wrdth ft L—lh n Thi— <br />rump l♦ Submersible❑ Turbine D Other HP Pimp Set It Standing Water Level <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATICN AND THAT THE WORT( WILL BE DONE IN ACCORDANCE V'ATH SAN <br />JOAQU IN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY t7EQENRED LICENSE IS <br />C ND ACTIVE Yi► THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />W a RS C ENSATIQf4-LAW . <br />Application Accepted By <br />Grout Inspection By <br />Purtpinspection By <br />Sal Boring Inspection By <br />COMMENTS <br />E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />T„nforporate Secretar&.. <br />Dale <br />Dale 1 Z <br />Date <br />Area_ (_( o _ Employee It* (tel' -v <br />U SPECIAL Well Permit <br />J WAIVER Received <br />Constructed Well Depth ft <br />wELL lFIIJNP P E RMIT <br />0 <br />0 <br />z <br />is <br />C d VZSCZ9960Z out S-1811uQ eoueinand dLti:-�O L 6 9l oaQ <br />