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l !hoc/ J-(4.,-) lil.)-1 /Ai ktvi <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (2591468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS NOI4 /4F 12(1 CITY/Z1P ,f/W14"5"..6___ ' <br />CROSS STREET e,",/,'Z',44*1-7.:Ce--67e14-"--____22: --/t_ie7._ PARCEL SIZE LI °I° LAND USE APPUCATION t* <br />OWNER NAME P71)/ .4-Y/Va4 "741-22-1 -e PHoNe s4 -75— 1/75-r <br />OWNER ADDRESS 2-7-ey 4-, yit.5;c70-72,5--__ crryis-rArezie _i zt_27 5- <br />eifiere,,ffitoll ii,-)trf4r .v-fir-.....me PHc.E <br />WELL CDPItgRiXel <br />Drilling Method ad Rotary 0/kir Rotary 0Auger 0Cable Tool DPush Point 0 Other <br />Proposed Wen Depth 27t-rft Excavation /".2- _ in diameter 00pen Bottom „Wray& Pack/Gravel Size _ Jr_ in diameter <br />0 ConductordCasing in diameter i Conductor Casing Depth ft <br />Wed Casing Diameter 47 in Thickness/Gauge/ASTM Sched _ele._. 7eD fiSteel pflastic 0Stainless Steel Pother <br />Grout Seal Depth ___, ft 0 Neat Cement (94/b bag/5-10 gal water) 0Sand Cement sack mix17 gat water <br />>Bentonite 120% solids) 00ther <br />Grout Placement Method,OPumpeti n Free Fall 1] Other 0 Retardant / Accelerator (name) <br />IPEoustm. installed By 0Driller 4rump Contractor0 Other <br />neencrete Pedestal II ions. Width _ / ft Length Z., ft Thick , 6 (1 in Dehriety Box OStove Pipe <br />ASubmersiblepTurbine Pother HP 1 Pump Set int) ft Standing Water Level 7 s-z-- ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAOLON 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 UCENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br /> <br />MINI VI * , ;„ t VANCE NOTtCE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 -7697 <br />SIGNED ,./1,41?-7-01.4r-----. TITLE , • se ". — DATE 1 <br />MOM 4171111;I=1:41 . <br />111111111MMIMINIIMI I <br />IIININIIIIIINNIIIIIIII III <br />111,11111111111 11101111111111111110111 ANN <br />NMI 111111111Wir,1111111 <br />tr <br />=111111111111111MIIIIIIIIIIIIIIIIIIIIIMIIIIIMIIIIIIIII <br /> <br />II II t:11111111 141 1111 ! ,YV"Illiaimminsoreirailiaormi <br />1111 Nil niiiMMENINIFIFif—=111111111i1111111111 <br /> <br />11ri IINIIIIIIII WIPP= rill <br />IIIIIIIIII IIIINI1141 'gift WWII BEM aiiiiini <br />iiiiiiiii ONSOMI Iiih- IPMlhIIIIIIIIIIIIIIIIIIIIIIIIIINIIIIIIIIIIIII <br />IIIIIEIIIIWPIMIIIMIMIIIIIFIMIIIIIIIIIIISMLIIIIIIINIIHIIIIIIIIIIIIIIIIIIIIIIIIIINIIIIIIIII <br />NIRIMMIIIIINIIM II r41141013101.11111111111111131 <br />IIIIIMIIIIIIIIIIIIMI kIPAINIPEUNIIIIIIIIIII <br />IIIIIIIIIIMIIIIIIIIIIINI II i4117%1VVIINEMMIIii <br />11111111111101111.1111.111 • 1111011.1110111110111111111111 IIIIIIIIIIIIIII 111111111112(01111,1111111111111111111111111111111 SIM 111111111111 1111011111111111111.41% Ilre' - MI NMI MB SSailOOV all CONTRACTOR <br />CITY/STATEJZIP Zrilf ee7S CONTRACTOR ADDRESS <br />SUBCONTRACTOR 4 tZe4LJ e,. ,4011-4---77/44 PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE V-57 0C-61 DO-OS fl other NUMBER EXPIRATION DATE <br />DomEsTic WELL SAMPLING: OGenerai Mineral/Conform Bacteria (4391) ODibromOchloropropane (4392)0Arsenic (4393) <br />I <br />INTENDED Use rnestic/Private 0 Irrigation/Agricultural ['Industrial 0Water Quality Monitoring cisoitSampling/Characterization <br />Public Water System It water System Name thffeveni from Owfux Lontsalgance or-Phone-Nurn tai <br />TYPE Of WORK }9New Weil 0 Replacement Well 0 Weit Alteration/Modification ['Other <br />* borings <br />0 Monitoring VVisfi(s), # of wells 0 Soil Boring(s) *c't tvs'ingt Geotechnical of <br />EjOut-Of-Service Well 000-0t-Service Well Renewal 0 Cross-Connection Repair <br />en Pump °Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />I Lae <br />0E, ARTMENT S ONLY <br />Application Accepted Sy.....__Sititt-J Date LS Area Employee 10411e2lift° <br /> <br />Grout inspection By Date C] SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br /> <br />Date <br />Date <br /> <br />o WAIVER Received <br />Constructed Well Depth ft <br /> <br />PE <br />Codes <br />SC k Received <br />Into By <br />Check*, <br />Cash <br />Amount <br />Remitted <br />rPermiti Date Service Request It Invoice TS Well ID* <br />6 t T-I C -7(9'i> 41 °° 9, IG cOR . D 0 2 2,7 ri <br />0 0 <br />o <br />0 <br />- <br />7 <br />7 <br />4 <br />.0 <br />93 <br />2 <br />2 <br />,2 <br />,-7 <br />6 <br />/1/01/15 <br /> WELL /PUMP PERMIT