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WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186E 6EAST HAZELTON AvENUE-STOCKTON CA 95205 -6232 (209) 4641-3420 <br />NON-REFUNr A.t C pFaulr WWW,$IQV V.DPgjeiid EXPIRES 1 YEAR FROM DATE ISSUED <br />FCROSS <br />ADDRESS V � � i�-G �:y� ('D j'� CrrY/Z!P S'T-� C�-T-DN 9520 <br />m <br />STREET�wro2APN,ysoaoa3 % A PARCEL SIZE LAND USE APPUCATIONNER NAME v'17-S <br />,II -Y o f �-MCIC-TZ3� PHONE CZo9)i3�- 9Z1Z <br />TOWNER ADDRESS / Z s N f L D o re1q- o o 5 r <br />CRY/STATFJZIP SG G <br />CONTRACTOR TK- I - e-0 V Jt1 7—y%,%� e-7104 C g S� <br />�/` t r'� �(LI LLIrJ �/ /PNONEjS,Sy)Z7%'GC�� <br />CONTRACTOR ADDRESS -i 6 I v 04 fjO I O A S i' <br />cmeisTaTE21P $3 N� Q GLvLE.0�lJQ 1ZZ/2�2 <br />SUBCONTRACTOR,CONSULTANTPiTpiNVA.-J,con-ax"sioI s1ec A.L7 QNl')Jyy-'3z7(Z <br />>UBCONR4CTOR/CONSULTANT ADDRESS837-U,"rif&STUG£CITISTATEILp-3./ oZGJCENSE x'657 C•61 -1 D-09 Oer NUMBER !�xpaA70NDATEl. <br />ISJND PARTY. D OWNER O CONTRACTOR :1 SUBCONTRACTOR/CONSULTANT &� <br />, <br />� <br />DOMESTIC WELL SAMPLING: u General Mineral/Coliform Bacteria (4391) E� Dibromochloropropane (4392) t-•: Arsenic (4393) <br />INTENDED USE J Domestic/Private C brlgation/Agricultural " Industrial n Water OuaBly Monitoring 7,Sol Samping/Cheracterization <br />3 Public Water System <br />K differer# from Owrnr. Mer Syrtem ema Conti! ema or hor+e <br />r <br />TYPE OF WORK : New Well - ! Replacement Well i WellAfteration/MOdification 14r0her l G G7 -)Q rJ <br />Monitoring Wen(s) # of wells F Soil 6omg(s) a oto n Geolechnical x of borings <br />Out-OfServire Well L Out-OfService Well Renewal U Cross -Connection Repair <br />New Pump :1 Pump Replacement D pump Repetr D Raise Wen Casio.- <br />IW r <br />Drilling Method ud Rotary ❑ Air Rotary C Auger G Cable Tool Push Point D Other <br />Proposed Well Depth (jP ft Excavation <br />lZ N diameter C Open Bottom r Gravel Padt,'Gmvsl Size in diameter <br />7 Conductor Casing in diameter / COnduCtor Casing Depth R <br />i Well Casing Diameter _ In ThicknesVGaugeIASTM Schad C Steel '' Plastic =Statile-c Steel C Other <br />Grout Seat Depth /(M ft C Neat Cement (9416 bagl5-10 gal water) C4end Cement _02_ <br />Bentonite ( h solids) � Other sack mixC7 gal water <br />wpb Gir.! ri,Jr <br />Grout Placement Method , Pumped ' Free Fall -� Other Retardant / Accelerator (name) <br />PEDESTAL Installed BY C Driller C Pump Contractor D Other <br />Concrete Pedestal .Dimension: Width ft Length ft Thick <br />� in Christy Box Stove Plpe <br />iPUMP = SubmersibleC Turbine 0 Other HP Pump Setfl Standing Water Leve! @ ! <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 THATMY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM <br />WORKERS COMPENSATION LAWS. W COMPLIANCE WITH ALL <br />MINIMUM 48 HOUR ALLVANCF NATlrr ocnlnoon <br />J DEPARTMENT USE ONLY <br />Application Accepted By �� !✓/r _ Date%,( _ Ansa � j �' i 4J r'1 E��e 0# <br />Grout Inspection By — Date 3 L i O SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />COMMENTS <br />Sail Boring Inspection By Date Constructed Well Depth _ft <br />- <br />p i s <br />f4T/e RMnklsd i I mel SMOdu._Reruast�L I Invoke 0 Well ID# <br />EHD49-M 6r111I019 <br />.� )`2711 �, 3 q -j WELL ~PEMUR <br />1?I A(r <br />Lj <br />I ?0?1 <br />COU <br />TM�NT Y <br />NT <br />