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MAIL EE <br /> WELUPUMP PERMIT NUv�`Yr a <br /> .lOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1968 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT yvwvv.slgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joa ADORE33 Y f / g� �•r CIT7lZ1P O m <br /> CRO33 STREET .// vAPN �j� �/� D <br /> i.-1 / �"rJ-/V�� PARCEL$IZEy _LANO UJAPPLICATIONI z <br /> OWNER NAME ` �I {/L PHONE <br /> OWNER �/ ���j <br /> OWNER ADDRESS Z S �y /�{ CITYISTATERIP / •aG�7i�jel, ,y �J���Y <br /> CONTRACTOR l�I_ Lc, PNOINEy�129-L(t�,}-62,-3 1 <br /> CONTRACTOR AwmEs3 t L/ `Q,`� CITY/STATEMPPU{��/l_�C.+ l )A Cl's <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS /+ �C�ITY//STATEIAP <br /> LICENSE /C-57 C-61 D-09 Other G 7 <br /> O NUMBER 1�"1J-7 CJ/. ) EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dlbromochloropropane(4392) Arsenic(4393) <br /> INTENDED UsE Domestic/Private/Irrigation/Agricultural Induslnal Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> II Off.—I Rom 0v Warr System Name Conrncl Nunn or Ph.-Numbs <br /> TYPE OF WORK New Well Replacement Well Well Alteratwn/Modification Other <br /> Monitoring Well(s) a of wells Solt Bodng(s)_ a"I b"""v` Geotechnical a"I d°""v` <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Purnp Replacement Pump Repair Raise Well Casio <br /> WELL CON3TRUCTION <br /> Drilling Method Mud Rotary Ali Rotary Auger ,Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel PacluGravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Walt Casing Diameter jq in Thlcxness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 ib bag/S 10 gal water) Sand Cement sack m;x/7 gal water <br /> Bentonite(20%Solids) Other <br /> Grout Placement Method Pumped Free Fal Other Retardant/Accelerator(name) <br /> ELr&STAL Installed By Driller Pu*Contractor Other <br /> Concrete Paclestpl- Dimansiddps:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible u ine Ot er HP Pump Set R Standing Water Level 1015 If <br /> 1 HEREBY E FY THAT I HA /PR PARE THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN TY ORDINANC 'ST TE 5, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURREN ACTIVE WITH LIF IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE ti PEN3ATTON <br /> M 48 HO A E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> t ,/^,/fit` <br /> SIGNE TITLE ✓ V \ DATE <br /> r. O <br /> l <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 044V�St Date/D-9-�S' Area Employee IDS <br /> Grout Inspection By Date_ SPECIAL Well Permit <br /> Pump Inspection By _ r Dale WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE I SC Received Check*/ Amount Date Permit/ Invoice M Well[Do <br /> Codes Into Cash Remitted Service Re uel N <br /> 4 <br /> E H'J 41JE 8111I.'C:9 �* ^ U�n/��/, (' /) V.f LL rPL,MP PERMIT <br />