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1 <br />WELLIPLI P PERMIT <br />SAN JOAOUIN COUNTY ENvmONlirNTAL IiEALTII DEPAnTttEtlT 1868 EAST HAZELTOU AVENUE - STOCI(TON CA 96205 - (209) 4GO.3420 <br />HERMIT <br />Joe ADDRESS C.4iJ •el J u lf N <br />W. KI/. <br />CROSSSTHEET 04ACOAJI)C r-IQVG APN <br />OWNER NAME <;=)IJ .10A1jL//n) /!/r <br />:TIONS EXPIRES 7 YEAR FROM UATE ISSUE[ <br />f_�..//ITYIzIP /MRAJ 1-EGT Gl 53 7 7 <br />EOL SIZE LAND USE APPLICATION l/ <br />PHONE <br />ADDRESS CITY/STATEIZIP <br />CTOR 6ALW/la�T /_o0Ro.Q6)1J 4eAzzfZa� (_.r7MP�tuV PHONE Sky-:�S9') <br />-�6-7r <br />CTOR ADDRESS .22..0 5 4"r,&TLr h'LA%{� CITY/STATEIZIP /-/X)/Lill <br />0JAJ21)i . i 4.6' 9Ju1y <br />TRACTOR L12-96f—_[)Q)u,/Au6 E T6�T,N� �PHHO,NE"/ . 2S ---3-60. <br />-�yf / <br />TRACTOR ADDRESS e-1 SD !'YOWL fC - m, CITYISTATEWJP• _ /-.{IIlZT/l�I /�/'7 -F/•/ 1'1 <br />Y. 657 C•61 _ D-09 _ Other Nur.wlt14 12-32 ExPIRATION DATE J2 <br />DOMESTIC WELL SAMPLING:.! General Mineral/Coliform Bacteria (4391) , Dibromochloropropane (4392) D Arsenic (4393) <br />INTENOEo USE 7 Domesgc/Private r:: Irrigallon/Agricullural Industrial i Water Quality Monitoring 1.1 Soil Sampling/Cheracterizalion <br />Public Water System <br />II dienem eam Ovmer: Waler Syelem Flame Contact Name or Phone Number <br />TYPE OF WORK k New WON -1 Replacement Well n Well Alteration/ModiGcalion R Other 6.9rffQQI1L <br />Monitoring Wells) M of wells Soil Boring(s) # a1 taring, 0 Geolechnical a orbar ngs Sm% //�� G�sr <br />........... <br />--- _- - u, Out -Of -Service Well _ Out -Of -Service Well Renewal r � Cross-Connecllon Repair ■ - i. y� D <br />J New Pump D Pump Replacement Pump Repair Raise Well Casing v <br />Drilling McUtod )( Mud Rotary 7 Air Rotary D Auger 0 Cable Tool ❑ Push Point _ Other AY 2 3 <br />Proposed Well Depth .200' It Excavation /0" in diameter G Open Bollom ;� Gravel PacwGrevel Size In diameter �� �V <br />f ConduclorCasing lndiameter / Conductor Casing Depth N ENVI NMEN <br />Well Casing Diameter _ In Th n{ ss/Gauge/ASTM Sched ! Steel Plastic I I Stainless Steel r Other T AL HEALTH <br />Grout Seal Depth X Neat Cement (941b bag/5-10gal waler) :- Sand Cement sack mixl7 gal w M(T/SE r <br />11 Bentonite (20 6 solids) D other RVI„ES <br />Grout Placement Method X Pumped ❑ Free Fall a Other ❑ Retardant /Accelerator (name) <br />PEDESUL Installed By L7 Driller n Pump Contractor - Other <br />❑ Concrete Pedestal 1LDimensions: Wdlh fl Length- R Thick( in )(Christy Box i' Stove Pipe <br />Pump D Submersible-) Turbine 0 Other HP Pump Set It Slanting Water Level it <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 />SIGNED. <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Illugrllon By <br />REQUIRED FOR INSPECTIONS - PLEASE CALL (209) <br />TITLE kiA;)ZR /A -"f AJ i7eA11- DATE y <br />RrT E N T UX 0 L - <br />ale � !'Area <br />Dale X <br />Dale <br />v Employee IDa <br />PECIAL Well Permit <br />WAIVER Received <br />t!jVeil Depth fl As <br />EV.043- I U.Vlrid <br />b%,ELL A'UMP PERAIn <br />