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WELUPUMP PERMIT <br /> - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REF NDA LE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AD E s <L— Ov �a of, ' `•,cr KZIy Or', ` ' I_s m <br /> f—r1'�APN -3 f} D <br /> CROSS STREET Af W Ct)t f\e r 4 SIl C '1-1 0' 5 7 PARCEL SIZE k LAND U APPLICATION# o <br /> 1 1 Ar pfd F <br /> OWNER NAME 1"ST l C-D. r1 AIF A�7 �(.�y�Jf^' L✓SG ��D--ZS S— DD w <br /> OWNER ADDRESS 1 /`�. n(:rTYISTATEIZIP �/'tP U'Y?-i( rr r Q \0 0"'/j� ?'f 9 <br /> CONTRACTOR !Y (i'T .�'7 I }� /PHONE r) /G' + Yoe <br /> CONTRACTOR ADDRESS -� CrTY/STATE/ZIP CSA I SSE T L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/SS��TATEIZIP <br /> LICENSE X -C-57 C-61 D-09 Other NUMBER LLl EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> F <br /> NDED USE DomesticiPrivate Imgation/Agricultural Industrial Water Quality Monitoring xSo I Sampling/Characterization <br /> Public Water System <br /> N mffomnf from Owner Welbr Syslam.Name C-1-1 Nems a Phone Number <br /> TYPE OF WORK New WBII Replacement Well Well AlteratiorvModification Other Q <br /> Monitoring Well(s) #of wells Soil Boring(s) x of bohn99 )'Geotechnical_fix of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair LU 00 LV( <br /> New Pump Pump Replacement Pump Repair Raise Well Casing O =n (C <br /> WELL CONSTRUCTION j <br /> Drilling Method Mud Rotary Air Rotary (Auger Cable Tool Push Point OtherN Z c j) <br /> Proposed 104 Depth It Excavation fir/ in diameter Open Bottom Gravel Pack/Gravel Size in diameter N W <br /> i3 o In I is Conductor Casing in diameter / Conductor Casing Depth It U = 2 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other ■ ■ ■ Q Ix <br /> Grout Seal Depth it Neat Cement(94 lb bag15-10 gal wafer) Sand Cement sack mix/7 gal water Uj cj�LU <br /> Bentonite(20%solids) Other <br /> Grout Placement Method')(Pumped Free Fall Other Retardant/Accelerator(name) YII� w <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions,Width R Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set # Standing Water Level tt <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. 1 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-rIP�LEASE CALL(209)953-7697 AA <br /> SIGNED TITLE Z f . ,1Q I-DATE 46--Zr-)-�� �/� • A <br /> rI <br /> ? 46 <br /> ryoF RFT q�Nry <br /> PA TMENT USY <br /> Application Accepted By �LGDate Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth n <br /> COMMENTS <br /> PE SC Received Check#/ Amount Data Permit/ Invoice N Well ID# <br /> Codas Info Cash a Itte e c a # <br /> WMEH043-06 m,u 14/14118 711�3/tiI j WELL/PUMP PERMIT <br />