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�. WELLlPUMP PERMIT <br />SA4 jo.QLM CrYINTY SUVAMMENTAL HEALTH DEPARTMENT 1863 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 460.3420 <br />NON-REI!'jNDABLE�P7ERmrr <br />CALL (209) 953-7697 FOR INSPECTIONS _ _ <br />E(X�PIR-E/S'1 YEAR FROM DATE ISSUE <br />_ <br />Y <� 21 `// --A - <br />✓/YIak }�� CmZP <br />JTVG�i�Yi <br />civ <br />Joe ADDRESS <br />�yJ A/ yn <br />C J -M A/ �y« <br />Y/C G �. _ �j O.O PAROEL SUE LAND USE APPLICATION N <br />CROSS STREET /// <br />�/CG`�i'iC i.r�I.O <br />a� - % �/✓�� <br />r 'y% <br />OWNER NAME <br />/ <br />(PHONe <br />t/�a <br />97 / �/ <br />/rO C rSTATl/LP <br />f? Q" Sox 77 0 <br />�Sas{{rtrpu.��o� <br />OWNER ADDRESS <br />/nw )4&ze2 <br />%��/�✓�' <br />PNONE� ���!/ <br />"'S�a�{lPO� <br />CONTRACTOR 4 <br />/ <br />_ /�O! <br />�(n/d !/icl/�, �-�* �` 7( <br />/nJ <br />CONTRACTOR ADDRESS Zoe 15 d % c? <br />CONTRACTOR <br />6 CITYISTATFIZIP <br />r� <br />—9/33 <br />SuecoHTRACTOR �" /%7"A`c <br />PHONE <br />S" <br />9j-1 <br />SUBCONTRACTOR ADDRESS /�O" ChLLf <br />Go>i �J CmrsTATEibP <br />LICENSE td457 D "1 0 D-09 <br />D Other NUMBER Ilee 7 4 <br />exrntA. DATE <br />DOMESTIC WELL SAMPLING. 0 General MinereUCOkform Bacteria (4391) D Dibrornochloropropane (43UZ) a Arsenic lgaaot <br />INTENOEOUae 0 DomNtiHPrrvato D IrrigationlAgricuaural C Industrial G Water Quality Monitoring YS(31lSamp6ngr-W"x4","W <br />0 Public Water System <br />i If dSlewe from Ownw: wow Sywke Nana Coraad Noma — <br />TYPE OP WORK 0 New Well 0 Replacement Well D WON AleratloiVMOdfioalion Other <br />D Monitodny WeN(s) 0 of w h, Vol, Bonny($) `4L s aeom Geotechnical �s dDOb ss <br />0 Out-0I-Ser*A WON 0 Out-OfSerA ce Well Renewal D Cross-Connactlon Repair <br />WILL g MetRUr'T10N 11pt..LO✓y -4 f f / r' r <br />Drilling Method G Mud Rota D 'o's Auger 0 Cable Tool 0 Push Point >< Other <br />Proposed Waa Depth Excavation In diameter C Open Bottom 0 Gravel PaduiGravel Size— In diameter <br />Conductor Caslny In diameter ! Conductor Casing Depth R t <br />Well Casing Diamelsr _ in Thic kness/GauyefASTM Sched ❑Sleet C Plastic ❑ Sialnless Steel 0 Other <br />Grout SNI Depth .5-0 R )4f.Neat Cement (94 b baPS-10 yet wsi'er) C Sand CameM sack mc17 gal water <br />0 Bentonite gm solids) ❑ Q01e( <br />Grout Placement Method 0 Pumped 0 Free FaN Other /rlr✓!�G ❑ Retardant l Accelerator (name) <br />PEDESTAL Installed BY 0 Driller 0 Pump Contractor 0 OtherR 7hfdc m C Christy 80: D Stow Plpe <br />0 Concrsb Pedestal ODknenslons Width R Lenylh —� <br />PUMP C SuEmerslbbD Tubine ❑ 011ier HP Pump Sel_ R Standing Walar Lewl m l <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. 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 />MINItyUM 24 H UR'QVANCI%�CE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE �/�• • �d C DATE /-/ cs -/�' <br />t NAR"FMENT USE ONLY <br />Application Accepted By Date 3 )-1 ' <br />Grout Inspection By Date <br />Pump Inspection By A Date <br />Soil Boringpection By t Date �© <br />dMENTS ns <br />/__ <br />Area 19 Employee ID# <br />C SPECIAL Well Permit <br />r, CJ. WAIVER Received <br />I De <br />M <br />84 <br />jh- <br />RI Cy. <br />A ii <br />qR ? <br />sq 8 <br />47,018 <br />N <br />yFp FNT �N�Y <br />,gRTMeNT <br />PESC Received Check#/ Amount <br />Codes Info By Cash Remitted Date <br />C4 S <br />Permit/ <br />Service Request # Invoice # Well ID# <br />3$ I D <br />EHD 43-06 6/01116 Ceq • / WELL /PUMP PERMR <br />i, q6 q,41l `6 <br />