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WELUPUMP PERMIT <br /> t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r N <br /> Joe ADDRESS I CITU/LP l m <br /> CROSS STREET APN (/&�(/�/PARCEL SIZE O• <br /> LARD USE APPLICATION# o <br /> OWNER NAME V Ir''ll� l.� y 1 1 1� 0—' � T .1!^�PH'�oEL <br /> 04 L <br /> OWNER ADDRESS v lS u' CRY/STATEIZIP{�l �7�„t �•1� <br /> CONTRACTOR r 71 <br /> rA 1 c ) ID P ONS <br /> CONTRACTOR ADDRESS C �'t_- �•,�'t <br /> CITY/STATE/ZIP _ -- �- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS f CITYYIISTATFJZ�17P 1/ <br /> LICENSE C-57 Y CC ' _ D-09 : Other NUMBER -J2y 1 EXPIRATION DATE L. <br /> DOMESTIC WELL SA PILING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE YrDomesticfPnvate ;i Irrigation/Agricultural =Industrial =Water Quality Monitoring _Soil SamplinglCharacterizalion <br /> -Public Water System <br /> It difl—nl Wm Owner. Water System Nanw Conrad Name M Phone Numher <br /> TYPE OF WORK G New Well . Replacement Well Well AlterationlModification --Other <br /> Monitoring Well(s) #of wells Soil Boring(s) n of loonnq' = Geotechnical p or bn0n9s <br /> ❑Out-Of-Service Well Out-Of-Service Well Renewal _ Cross-Connection Repair <br /> C New Pum um Re lacement Pump Repair _Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger _ Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter -Open Bottom -. Gravel Pack/GFavel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter In 1 hickness/Gauge/ASTM Sched „Steel --Plastic Stainless Steel - Other <br /> Grout Seal Depthft 1. Neat Cement(94 lb bag/5-10 gal water) 7 Sand Cement sack mixA gal water Y <br /> -.Bentonite(20%solids) Other + <br /> Grout Placement Method :.Pumped Free Fall -.Other =Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller =Pump Contractor - Other ,"yKj•e <br /> Concrete Pedestal .Dimensions Width 11 Length ft Thick in _Christy Box -Stove Pipe la <br /> s N <br /> uMP Submersible_Turbine -'Other HP Pump Set ft Standing Water Level � k A ✓Qq ��J <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN !-i��VIR���NCpU <br /> , , . THAT MY REQUIRED LICENSE IS <br /> CURRENT WORKERS AND ACTIVE <br /> WITH <br /> H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL TND,�OgRTTq N <br /> JOAQUIN COUNTY ORDINANCESSTATE LAWSAND RULES AND REGULATIONSI ALSO CERTIFY � <br /> COM <br /> `UNI 48 H ADV,4NeE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> '6 <br /> SIGNED T.•vim- TRLEJ ,v DATE (- 7 J <br /> AI A <br /> S All <br /> PA TMENT US N L Y `mow <br /> Application Accepted By Dale Area- /Q� Employee ID# <br /> Grout Inspection By ' Date SPECIAL Well Permit <br /> Pump Inspection By a T-q Date I.-. r I IC L WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth H <br /> COMMENTS <br /> PE SC Received Check## Amount Date PermlV Invoice# Well ID# <br /> Co s Info Ca Remitted Service Re uest# <br /> n1 IN POO 4C 14 , <br /> i <br /> E�DAyrAi•e�nsed A'+.A�19 �J/J�'�'`�/]��/y//•/^I <br /> 2-XWELL/PUMP PERMIT <br />