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PHONE <br />CITY/STATE/ZIP 1-e...____ARAZ <br />PHONE <br />I -7 <br />• <br />0 6 f3a.v.,21,14 <br />001.4i <br /> <br />41 <br />Mail I <br />Appiication Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />_ ea, fame, <br />Soil Boring Inspection BL <br />COMMENTS <br />VU <br />,seiimi• A. — <br />at. Alr% "- <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE n C 57 DC-61 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT WELL/PUMP PERMIT / L/ NON-REFUNDABLE PERomairilur,MI: <br />itorgsw09 953-7697 FO NSPECTIONS <br />I <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209)468-3420 <br />CROSS STREET (.4.10240 <br />JOB ADDRESS 4--L) <br />/ <br />APN <br />zee, Muria", 0 3 -- 060 - <br />0 <br />44 - <br />PARCEL SIZE 3 2t AID USE APPUCATION # <br />C CLINHONE <br />fl/STATE/Zip <br />V <br />Cct 5)(1 <br />CITY/STATE/ZIP <br />TYPE OF WORK aiiciew Well ID Replacement Well pWell Alteration/Modification Li Other 0 Monitoring Well(s) <br /># of borings of wells D Soil Boring(s) DOut-Of-Service Well DGeotechnical DOut-Of-Service Well Renewal EiCross-Connection Repair <br /> <br />e Pum DPum R lacement 0Pum. Re air <br />Raise Well Came. <br />Drilling Methodud Rotary DAir Rotary DAuger 0Cable Tool D Push Point 0 Other Proposed Well Depth__`"_.,?_,V__ ft Excavation j1,.._____ in diameter DOpen Bottom Li Gravel Pack/Gravel Size in diameter <br />DConductor Casing in diameter / Conductor Casing Depth , ft Well Casing Diameter in ThicknessiGauge/ASTM Schect OSteel APlastic DStainless Steel pOther <br /> <br />Grout Seal Depth 7_ .T.,' ft Li Neat Cement (94 lb bag/5-10 gal water) DI Bentonite (20% solids) DOther XI Sand Cement;L:..1____ sack mix/7 gal water Grout Placement Method DPumped D Free Fall DOther <br />PEDESTAL Installed By Driller D Pump Contract r 0 Other "'Concrete Pedestal [Dimensions Width ft Length <br />'PUMP <br />'..,..bmersible0Turto+ne Otter <br />ft Standing Water Level ft I HEREBY CERTIFY <br />THAT I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />WORKERS COMPENSATION LAWS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />MINIM 442ZOUI_IVANCE NOTICE <br />REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DATE f.1.-- <br />1111111111:11111fte-; <br />0D-09 °Other <br />NUMBER f.i_2_2_1_FLL EXPIRATION DATE <br />INTENDED USE <br />DOMESTIC WELL. SAMPLING: <br />['General Mineral/Coliform Bacteria (4391)0DibrOMochloropropane (4392)0Arsenic (4393) P. <br /> Public Water ft from Owner System <br /> <br />omestic/Private Irrigation/Agricultural DIndustrial OVVater Quality Monitoring pSoil D different Sampling/Characterization <br />ame <br />ra1fNywor e um er <br />aortsaMIgs <br />WELL CONSTRUCTION <br />DRetardant / Accelerator (name) <br />ft Thick in ['Christy Box ['Stove Pipe <br />HP Pump Set <br />SIGNED TiTLE_ai <br />TMENT U•E •NLY <br />,000 <br />idn Date <br />Date <br />Date 01 / lk,V 10 V C\ <br />Da <br />13 41Ma 0. <br />il 14). , <br />2C <br />WAIVER Received <br />Cons ructed Well Depth055. ft <br />DX <br /> <br />Area <br /> <br />Employee IDit <br />SPE IAL Well Permit <br /> <br />U <br /> <br />Amount <br />Re itted <br />taroaiminimigilatiMMUnii MIME • Lailipalmilim 'cm <br />WELL PUMP PERMIT <br />A.E SC )1444)vad <br />:odes <br />, /.1B,e <br />Poo <br />Permit/ <br />Service R uest Invoice N <br />EHD 43-06 8/01/16