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WELL/PUMP PERMIT <br /> - + SAN JOAOUW COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAMTON AVENUE-STOCKTON CA 95205 4232(209)46&3420 <br /> T NON-REFUNDABLE PERMIT W ov.orglehd EXPIRES'1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS / 4CTr2)P <br /> CROSS STREET /' - I \� C-T �T ;•r Lt1 4�LA. • . <br /> �� wPN I(l I-i i(J-`✓� PARCEL S�y•lr�J LAND USE APPLICATIDN x p <br /> OWNER NAME tt.(=G :'�47�- ' a <br /> � C:�., s.rwc%fa•i. PHONE <br /> OWNER Amicus s'.lo(s t c.De^R -F.£L1� I�GI-FD CINMTATEZP <br /> CONTRACTOR l?2 j)9fLU1U)A- n:.7n�r>/L 1,r1 PHONE 91 •-slam' ;'G'.r.` <br /> CONTRACTOR ADORE= 1400 K.rTCA A4 i! RCOD <br /> CRYISTATFIZIP <br /> SUBCONTRACTOR/.ONSULTAt1T fZAli<IcY �srG-7'ct.fi n%fCJ'}[..- �rV ir_ PHONE 91(o--37J—o,}3q <br /> SUBCONTRACTORICONSULTANTADDRESS 31417 561r•C4VU. P-1-VP [OG CiTYISTATEMP 6(JrsTS, uCP,, 4--,V70, C4 <br /> LICENSE !y C•57 C-61 L:D-09 i.Other NUMBER /00(0095 ExPIRATTON DATE <br /> BIWNG PARTY: OWNER CONTRACTOR YSUBCONTRACTORICONSULTANT <br /> DOrESTiC WELL SAwPLINc: General Mineral/ColNorm Bacteria(4391) Dibromochlomprnpene(4392) Arsenic(4393) <br /> INTENDED USE "'DomestbPrivate ::Irrigation/Agriculurai 1 Industrial =Water Quality Monitoring X Sail Sampling/Cheracterization <br /> Public Water System <br /> N ddlwwg from Ow Wald Systvn Name Carnad Na or Phare Numbw <br /> TYPE OF WORK „New Wal 7 Replacement Well E Well AlterationlModificalion :Othw <br /> :7 Monloring Well(s) k of wets Soil Boring(s) a of har"'9' XGeotechnical a m eorin�� <br /> OutOfServix Wel <br /> ..Out-Of-Service Well Renewal ::Cross-Connection Repair <br /> '1 New Pum :;Pump Replacement ::Pump Repair L Rase Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method :I Mud Rotary 71 Ah Rotary Auger ::Cable Tool _Push Point C Other <br /> Proposed Well Depth IQ To 'LCT R Excavation 4k,-r in diameter Open Bottom .:Gravel Pack/Gravel S¢e in diameter <br /> ,7 Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_in ThictnesslGauge/ASTM Sched SteelPlastic :1 Staiinless Steel F.Other <br /> Grout Seal Depth Ds.of It X Neat Cement(94 lb bag/S10 gal water) r:Sand Cement sack miad7 gal water <br /> L:Bentonite(20%solids) "Other <br /> Grout Placement Method !Pumped Free Fal F Other Retardant/Accelerator(name) <br /> (�PEMSTAL Installed By 71 Driller :Pump Contractor A Other <br /> L L]Concrete Pedestal t7Dimwislons:Width ft Length ft Thck In -Christy Box E'Stovc Pipe <br /> PUMP ;]SubmersbleLl Turbine Other HP Pump Sat _ ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AF�VECALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br /> WORKERS COMP TON LAWS. <br /> P.,Ui' ,SCE NOTICE REQ'-"Z i F O^-X'S%cCT[0XS-PLEASE CALL(209)9.53-7697 <br /> SIGNED TITLE �1 DATE t� -�L} `•� <br /> r <br /> PA <br /> gL/llV <br /> O �U� <br /> EA,gR��N 7'/ <br /> H I F--__- — —L :fl-1——I I <br /> J' DEPARTMENT U ONLY <br /> Application Accepted By —�` �—' Date C 7 �d'z O Area +J r Employee IDY <br /> Grout Inspection By Date /� SPECIAL Well Permit <br /> Pump Inspection By Date V C WAIVER Received <br /> Sod Boring Inspection By Date 42 Z.6 Camttructed Well Depth It <br /> COMMENTS 1=' <br /> PE SC Received Amount Date pwmiv Invoice Well IDS <br /> Codes Into RamM*d Request!< <br /> 50 <br /> EMD 1106 6l11rYJ19 <br /> (VELI lPl1AtP PERem <br />