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WELL/PUMP PERMIT <br /> JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 a68 EAST HAZELTON AVENUE-STOCICTON CA 95205 (209)668-3420 <br /> 110N-REFUN RMIT CALL 209 953-7,537 AOR INSPECTA NS ( 9 SEAR a T ISSUED <br /> Y `B ADDRESS �J� UA <br /> I N <br /> CROSS STR - _APN (/ �( EL SIZE _LAN U APPLI nON I I Y <br /> rJ'NN--O NA "4a I G `c V I 11 S <br /> �'In i m <br /> I p � ✓ �r- ✓ J w <br /> �-I �'�` Pn E <br /> OWNER ADORE���,,1 G ,y^' G1 t� \ <br /> •Yi� � �j� P��• `-" - ��/�y�� CITYISTAT P' • / <br /> �ONT.iACTOR C-'Y -" 1/ _-I� P ONE <br /> 1 1 <br /> CONTRAC70R ADDRES$ 10 CITY/ TATfzIP 5 v <br /> SLBCONTRAC70R _ PlIONEIV <br /> St:a CONTRACTOR A0OPESS N 1 <br /> /// ��y�tCITYo/�nAT�EJI/AP <br /> -CENSE -57 V C-ot D-09 0th NUNIB R ` `"' �✓ v EXPIRATION DA <br /> 3OME5;TIC WEut S j4PLING: General Mineral/Coliform Bacteria i43yt 1 Oibrom.ochloropropane(4392) Arsenic(4393) C <br /> iNTENDED USE V ComesticlPrivate Irrigation/Agricult.iral Industrial Mater Quality Monitoring Soil Sampling/Charaderiza0on _i <br /> Public Wa:er System ; <br /> A a:r!erenr Iron Jwrrr. Nater system:.;^,� COntaCt Name or Phone Number <br /> -rpE OF WORK Nev,',yell Replacement Well Well A!tEraue^�'•.lccif.reen Other <br /> Monttor:r.g.'well(sj 4 of wells Sod SCrI;r,: e 0 tlonngs c:banr.;c i <br /> -- Geotechnical <br /> Cm-Cf-ServiceOut-Or-SEn1!cS:'.en R=nswal Cross-Connection Repair <br /> _ N&,,:z,ump Pump Replacement pu^C _ Raise Well Casing <br /> WEL'_CONSTRUCTION <br /> C-•lling Method Mud Rotary Air Rotary Auger Caoie-cc• -'ash Point Other <br /> Proposed Well Depth IT Excavation �n C are r ! <br /> Open Bottom Gravel Pack/Gravel Size In diameter <br /> Conductor Casing in diameter , Conductor C,.Sir.g CEptn ft <br /> Well Casino Diameter_:n Thickness/Gauge/ASTM Schac Steel Plastic Stainless Steel Other I I^ <br /> Grout Seal Depth ft Neat Cement(94 Ib bag•5-'u gal rrarer) Sand Cement sack mix/7 gal water I 1 <br /> Bentonite(209,solids) Other r� <br /> �rout Placement Method Pumped Free Fall Other Retardant!Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Clher ! <br /> oncrete Pedestal Dimensions:Width_rt _dnr••F_ ft Thick in Christy Box StQve Pi <br /> PUMP Suomersible Turbine Other cP _ Pump Se _ft Standing Water Level ft <br /> HEREBY CERTIFY THAT ! HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ! <br /> -OAQUIN COUNTY ORDINANCES, STAT LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> CURRENT AND-AC-IVE WITH THE C FORNIA MIT ACTORS STATE LICENSE BOARD AND 7IAT I AM INCOMPLIANCE WITH ALL <br /> '.V fRKEIFS COMPENSATION LAW �l <br /> MIN MUM 24 HO IZ�NZ5T1� MARE6-^RC;NSPECTIONS-PLEASE CALL(209)95 -7697 <br /> S13NE^ — /r `\' erYl f� rn Gvt/J <br /> I ITL DATE_Wt !tN <br /> Oct <br /> I i <br /> I I l i <br /> I <br /> IJOgQ ®�� <br /> I <br /> PA TM _ U E N L Y <br /> �coh,;vaan A-eorc-iS. 9 - <br /> z Area <br /> InsPeC.icn 2; Employee!QA <br /> Da"inspection 8 SPECIAL Wel(Permit <br /> WAIVER Received <br /> Stn <br /> B. Inspec[Icn By <br /> Oat'' Constructed Well Depth <br /> It <br /> PE SC Received I heck* Amount <br /> 'o a Info g PermiU <br /> s milted `Oat' Invoice x <br /> I Service Re uest# Well IDIS <br /> - I � <br /> WELLrFJ.,1P=E3M{ <br />