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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT [ Z CALL 209 953-7697 FOR INSPECTIONS EXPP�IRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS _ ' 1 S �/ / e �c/ p CITY/ZIP ra r � 9S3/i!� N <br />CRO55 STREET ,8Ie We T7 /�tr` ' APN _�4PS- t%OQ /'6 D <br />✓ y� �/ //'t� ry (Ar" <br />/ Ifs. PARCEL SI2 AN0 USE AAPPPLICATTION 0— <br />OWN <br />7 <br />OWNER NAME ,��IJ[Q�n,fit. lJtu�/�t_js/Ar�"J I, V'�'' /� PHONE �`V/ �Of�Q•�-W/'/// io <br />OWNER ADDRESS 3%/ 7otiC SJ•���0/ff R Ift ��! (0 CITYlSTATE/LP TIQC Q� /4S�7VCJ^J � <br />CONTRACTOR / T / �I (, / .,.) L"} /W l_.l-i `(J r� / // I% Gr Inc. PHONNE _ �j �/ /��'tO O4/�jOnJ/ <br />CONTRACTOR. ADDRESS eC/r.��'3 CITYISTATE/ZIP ��1)/00 _ `A <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE171P <br />LICENSE 0AC-57 C-61 D-09 Othef NUMBER �O � EXPIRATION DATE G <br />DOMESTIC WELL SAMPLING: - General MineraliColiform Bacteria (4391) '� Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE DOmeSbnJPnvale Imgation/Agncultufal JK Industrial - Water Quality Monitoring L� Soil Sampling/Characten2ation <br />Public Water System <br />It aftcrent from C— Wl!er System Nemo Co,uct Name or Prt-e Number <br />TYPE OE WORK C New Well KReplacement Well ": Well Alteration/Modificawn Other <br />^_ Monitoring Wells) # of wells - Soil Boiing(s) a of b. -Ni Geotechnical 0 Y t—ngs <br />0 Out -Of -Service Well Out-Of-Semce Well Renewal Cross-Connectim, Repair <br />D New Pump . Pump Replacement , Nllmp Repair 1. Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method V Mud Rotary _ Au Rotary . Auger Cable Tool Push Point Other <br />,Proposed Woll Depth/000 ft Excavation a;?8 in diameter - Open Bottom }d.Gravel Pack/GravelSize yi/0 in tl`iameter <br />xConducter Casing -4, in diameter / Conductor Casing Depth G%�ft f /�/D s et Ui1 <br />Well Casing Diameter hicks Gauge/ASTM Sched • 3 7S �Stoel : Plastic Stainless Steel _ Other <br />I / rout Scat epth Neat Cement (94 16 bag/5- 10 gal AWer) .LSand Cement l St?W sac -T.-7 gal water <br />Bentonite (20% solldsi _ Other 5 y r <br />5 Jig (Grout Placement Method VPumpeC _ Free Fall I Other Retardant / Accelerator (name) <br />t� PEDESTAL Installed By - Cnller plPump ContractorOther <br />i Concrete Pedestal -Dimensions Width _ ft Length H Thick in Christy Box Stove Pipe 'V�^ <br />PUMP = S,.brnersible- Turbine = Other HP Pump Set ft Standing Water Level <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT <br />JOAQUIN COUNTY ORDINANCES, STATE MWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE ✓©q `� ?018 <br />CURRENT AND ACTIVE W TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT)j (jj <br />WORKERS COMPENSA Ws. �F,gLT "? 'I COC+617ON <br />MIS �UyM� '44%� �fR/ADVANCE NOTICE REQUIRED FOR Imo! u �SQn EASE �rALDA E095 5/O69/� y0FpgR M N � <br />SIGNED !l lA � �LJ� N J TITLe Y�`7 M <br />PA TMENT U E O Y <br />Application Accepted By Date Area <br />Grout Inspection By Date SPECIAL <br />Pump Inspection By Date WAIVER R <br />Sod Boring Iactt or B Date Constructed Well Dep <br />COMMENTS WA3AJrr / �� /�� -��7 ` G�Z <br />t <br />Employee IDS j�� <br />Well Permit <br />eceived <br />CCi <br />in tt <br />Amount I Data _... Pe�u.__. .. <br />Invoice # <br />VE® <br />1o,s <br />IH�EALTH <br />Well IDs t.171f <br />�/,3/f <br />[nC'3yA a.0 •;,. - --- (` .� J, i` �C 41c ( L')1•t"I VLA.! K'ri LYS 'Ct%rm WELL PrEn•!I- <br />