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WELL/PUMP PERMIT <br /> SAN JOAmm CoUNtY EN1/wwENTAL HEALTH DEPAR111ENf 1868 EAST HA>7 miii AvENt1E-STOCKTON CA 86206 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 208 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> _La <br /> Joe ADDRESS CrTYlLP A <br /> CROSS STREET_Tt-fw era I N� APN � ` ' PARCEL SIZE LAND USE APPLICATION# S <br /> OwNER NAME IO.h IN!Q `l 0 �.J�a,J PHONE P <br /> OWNERAWRESS ?��LA ZZ-*P—b.M in 4\1e , Cm/STATE/Zr ES C (Q `\ 0 n^ 04, 'lQ S <br /> CONTRACTOR ,`PHOIE O Y 3- Z 4 0� <br /> CONTRACTOR ADDRESS (r 1)4 �'- sehi i L� RA CRY/STATEal A UO V,SOn C Ct <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cm/STATE2D <br /> LK;Epm -i CS7 C-61 n D-09 -]Other NUM EXMRATMN DATE <br /> DoMEsm WELL SAMPLING: J General MineraVColiform Bacteria(4391)L Dibromochloropropane(4392)a Arsenic(4393) <br /> INTENDED USE X Domedic/Private n Irrigation/Agricultural r- Industrial -1 Water Quality Monitoring :-1 Sod Samping/Cheraderimtion <br /> L Pudic Water System <br /> If different from Owner Vfthw SYalem Nane Contact Name or Phme Number <br /> TYPE OF WORK L New Well -Replacement Mall U Well Afteration/Modifcation r'.Other <br /> F-.Monitoring Wallis) #of wells -1 Soil Bonng(s) s d bx vs -1 Geotechnical t a bonnps <br /> F Out-Of-Service Well -1 Out-Of-Service Well Renewal r-Cross-Connection Repair <br /> Pump Pump Replacement -1 Pump Repew I- Raise Well Casing <br /> WELT.CONSTRt1C71DN <br /> Drilling Method F Mud Rotary Air Rotary -1 Auger -1 Cade Tool -1 Rah Point F, Other <br /> Proposed Well Depth II Excavation in diameter L Open Bottom n Gravel Pack/Gravel Size in diameter <br /> F'Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thidunss/Gauge/ASTM Schad n Steel C Plastic f1 Stainless Steel n Other <br /> Grout Seal Depth R L Neat Cement(94 lb bagr5-10 gal water) L Sand Cement sack mixl7 gal water <br /> L Bentordte(20%Solids) L Other <br /> Grout Placement Method U Pumped U Free Fail L Other L Retardant I Accelerator(name) <br /> PEMTAL Installed By 7 Driller Pump Contractor -1 Other <br /> F.Concrete Pedestal n dons:Width R Length R Thick in n Christy Box -1 Stove P'pe <br /> P S.bmenable_Turbine L Other HP Pump Set R Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUNtED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM M COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUA APV/A�NaC`E`NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953-76697 <br /> SIO- �o i,4 It ll / TrtLE DATE -/— <br /> ; Y <br /> Zcevzo <br /> 21 2018 <br /> JOAQU) <br /> AN ARD pA'fRNo,A 7Y <br /> /(J <br /> M E N T U E Oom LY NT <br /> c <br /> Application Accepted By to Area Employee ID# <br /> Grout Inspection By Date f l U PECIAL Well Permit <br /> i <br /> Pump Inspection By wnr:.�L� 'l ,^ -y 011ila I L (7 WAIVER Received <br /> Soil Boring Inspection By Dah Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received (Ch6cligily Amount Date PemoW Invoice# Well FOX <br /> C Mfo fled rvice nest# <br /> EHO 43-M a101/1E VVE L/PUW PERNT <br />