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10 <br />'WELUPUNIP PERNwr <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARr1.1 : ' 13u3 EAST HAZEITQpI,'��EfrGE-SrOCKTON CA 35205 •ri232 (209)108.3420 <br />NON-REFUNDABLE PERMIT WW�W.STOV.1or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />!JCB AODRE3� �bd I • r r V �Gb l� CIT, Z.� T`r((i.�t 1♦ 5.?j 1 i T: <br />I71 C �y� Cines <br />CROSS STREE",� vV�L_ A?N f ��+r 1 ( _PARCEL SI_=!�' �N'T\. LAND USE APPLICATION $ I I a <br />CI,vNER NAME T (-u J 5.:�.i�i 1� DLi� `•�� �.,r `� v `� PHONE <br />OWNER ADDRESS _ 3, <br />l; r ( AA / CITY/STATE�ZIP <br />CONTRACTOR VU`) �PHONE <br />W -/ .2 IVbqi-.o <br />0 J' <br />CONTRACTOR ADDRESS , �/ tJn.l �7 IVT `C /jam CITY/STATE/ZIP G,w c rag r1-�SZ�3Z L j <br />SUBCONTRACTORICONSULTANT l♦y Vw`llµc �' {,..(A`T+� V �J �7Vu �+""� �� tPHHONEE C `I �o "J���} I � J <br />SUBCONTRACTOOR/CONSULTANT ADDRESS IV �O 1 CA�� IUI ��, CITY/STATEEIZI`P !r"" � I ' Va-' L`.%�. r � ' <br />LICENSE Y„-57 _ C-61 C D-09 _ Other NUMBER O •v EXPIRATIONDATE r /Jy UL2 <br />BILLING PARTY: OWNER _ CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: _ General Nlineral/Coliform Bacteria (4391) Dibromcchlorccropane (4392) Arsenic (4393) <br />INTENDED USE _ Domestic/Private Irrigation/Agricultural -- Industrial r Water Quality Monitoring ' oil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or ?hone Number <br />TYPE OF WORK - New Well Replacement Nell -//Well AlterationiModification --Other <br />Monitoring WellY <br />Well(s) # of wells Soil Boring(s) 2- 4 f borings Geotaclnlcal sur bonugs <br />Out -Of -Service Well C Out -Of -Service tPlell Renewal Cross-Conrection Repair <br />= New Pumo G Pump Replacement C Pump Pepair Raise Well Casing <br />Drilling Method J Mud Rotary - Air Rotary v,"\uger , Cable Tool Push Point - Other <br />Proposed Well Depth 15 Excavation in diameter - Open Bottom s Gravel Pack/Gravel Size in diameter <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness,Gauge/ASTM Sched C Steel = Plastic C Stainless Steel - Other <br />Grout Seal Depth 115 ft ±-treat Cement i94 Ib bag,5-10 gal water) Sand 3ament saCK rial7 gal water <br />(Bentonite (20% solids) - Other Grout Placement Method - Pumped _ Free Fall eOthef T� c7iiiQ I eta n ccelerator iname) <br />PEDESTAL Installed By _ Driller C Pump Contractor C Other <br />Concrete Pedestal =Dimensions: Width ft Length ft Thick in D Christy Box C Stove Pipe <br />PUMP Submersible = Turbine D Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY 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 />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />DEPARTMENT <br />rU E qNLY <br />Application Accepted By �' Date J of Area -t� �ru6Employee ID# <br />Grout Inspection By _ _ Date SPECT Well Permit <br />Pump Inspection By _ _ Date -j WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth ft <br />PE <br />SC Received Check#/ <br />Info Cas <br />Amount Permit/Codes <br />Remitted ata Service Re uest # Invoice # Well ID# <br />14172 <br />sa <br />WELL PI,MV'ER.W1 <br />% <br />