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R <br />WELL/PUMP PERMIT <br />SAN JOApmN Cotam ENvWNIdP.NTAL HEALTH IIEPARTMENT 1888 EASTHAZEUGR AVENUE+- STOCKTON CA 96205 - (209) 4683420 <br />NON-REFUNDAt PERrdr7 r_ -CALL (209) 9533-78%? FORiNspgC _/,y EXPIRES 1 YEAR FROM DATF Is.gifrn <br />V C"ISTATE/ZIP <br />r-£ Sul <br />� ftp jrh�T' <br />usli - - yc -i J • , v 7 v "CITYISi'AT[/Z� <br />.. C17aY1�tALtdZiP Ql ilh <br />wCHHSE )(C-57 ❑ G$1 ❑ "a ❑ OSh9r NUMBER - / / 7 S % EXPIRATION DATE <br />oMEBTkc WELL SAMPuNO; G General WneraUCO tbrtx113acteda i(4391)_D DIbramochbroprowe (4392) 3 Arsenic (4393) <br />ri—m®ilei ❑ ❑wnesOc)Private 0 IrrigaUan/AgrfcuItural ❑ Indu9ldal O ftlarquaftMonilarklg Sol! sampnng/Charictanzatian: <br />❑ Public Water System <br />i(dtlfennt hum Owner. WOW,.`,�yft{apNYmp CornnK Nanre or PFgre Number <br />TYPE OF WORK ❑ New Well Cl Replacement Well iU Wait AlteratlonNodlflicallon a Other . <br />❑ Monitoring Wallis)J_ # of wafts: tT So8 Barfng(s) PuMcwinpsA9�GeeteCllhlCaf hedngs. <br />U out-Ofsetvice Well f) Out -Of -Service Well Renewal D San9s F, M�eclian Repair <br />❑ New Pump D Pump Replacament 13 Pumo f "Ir 0 Ratde Well Casing. <br />WELL CONeTRUOTUIN, — <br />Drilling Method D Mud Rotary D Alt Rotary ❑ Auger. p Cattle Tool � Push Point ❑ Othec <br />Proposed Weil ❑epNs�_ft Excavation 31 T- In diameter a Open Battnm a Grev6tP ow S(za yidieitrefe <br />0 CarlducWCask* indiameW / ConducterCasing Depth _It <br />Well Caning Utantater _ in Thickness/GaugafAsTM sched li Steel O Plpa6e B Sf Nilas9 §Feet ,p QOter <br />Grout Seal 08011 ft Neat 'Cement (941bbeg3logal watad ❑Sand Cement aeckinGd U*vAjW <br />O BentoN ite (20% solids) U Oew <br />Grout PlacementAl0bod I.PMW. ❑ FmeFell ❑ Other ❑ i2eterdaMlAiX lsrator{Hams <br />i iNlsfallad By ❑ Driller D Pump Cantmctdr O Other <br />D GoneretePedestal 0Dlmenslans Width. 'ft Length ft Thick In ❑ ChrtstyBox ❑ 8twa fte, <br />PwtP ❑ Submersible[] Turbine ❑ 0ther HP Pump Bet ft Standing Water Leve! ft <br />I HEREBY GER THAT I HAVE PREPARED THIS APPLH,ATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN C I,DINANCES, STATE LAWS, ;+„JD RULES AND R[6ULATIONS. I ALSO CERTIFY THAT MY' REQUIRED LICENSE IS <br />CURRENT AND AG� WITH T E CAUFORNTA CONTRACTORS STATE LICENSE BOARD AND THAT f AM IN COpiPLIANCE WITH ALL <br />WORKERS COIi{P N l A <br />MINIMUM NOTICE REQUIRED FOR 1 �EyCyt�10 -PLEASE CALL (208) 9/53 697 <br />SIGNED _ TITLE_ • '► N L DATE 3 l3 , <br />Apppostla , Apoeptdd By <br />Gtbut inspeglon W, <br />Pimp kwed(on BY <br />Soil Boring Inapictlo 9y <br />MENT U 0 Y <br />Aram F.mdoyselD#�E?� <br />� Oete f3 SPECIAL Walt Permit <br />�� ❑' wAIv,R Received <br />VML~MMff <br />t <br />0 <br />110 w <br />VML~MMff <br />t <br />0 <br />