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ov9000 1y f/vc rc r cr c <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAaT HAZFLTON AVENUE•STOCKTON CA 95205-(209)468.9420 <br /> NON-REFUNDABLE PERMIT CALL 208 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOe ADDRE88a � CITfIZIP <br /> CROSS STR `,•/p /��Q'�•11O 17�V/0�� ARCELSIZE_J,' LAND Use APPLICATION 0 fib^ <br /> OWNRR NAME � >MC,u KT/_ /'� 1 �)�[i� PHONIC r� <br /> OWNER ADDRESS / CITYISTArWZIP <br /> CONTRACTOR Ai 101""/ z) PHONE-20T— <br /> � <br /> CONTRACTORAOOR8t18L .c �// ,�('g CITYISTATEIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATaIZIP <br /> LICENSE 0 C-S7 t}et 0 D109 0 Other NUMBER EXPIRATIONDATE <br /> Dweanc WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropsne(4392)Q Arsanic(4393) <br /> INTENDED UBa DomoStIc/Pdva(9 U Ir igalion/Agricullural 0 industrial 0 Water Quality Monitoring 0 Sol]Sampling/Charactotlzalton <br /> C Public Walor System <br /> If dllfomnl from Olmoc Watcr ayatam Nomo Conlld Nem*or Phuo*NU ter <br /> TYPP OF WORK O New Www R Replacement Woll C Woll Afterdtlon/Modification 0 Other <br /> 0 Monitoring Welt(s) #of wells 0 Soll Sodng(s) a of boring U Gooloohnical tr nt aann0s <br /> C Out-Of-Service Well 0 out-Of-Seryloo Wall Renowal 0 Cross-Connection Repair <br /> New Pump 0 Pump Replacement C Pump Re etr M Raiso Woll Casin <br /> W66L CONeTRUCTIDN <br /> Drilling Method D Mud Rotary 0 Air Rotary n Auger i?Cablo Tool 0 Push Point D Other <br /> Propocod Well Depth Excavation_ In diameter C Open Bottom 0 Gravol Pack/Gravol Size,,,,,,,,,,,,_„In diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth n <br /> Well Casing Diameter^In ThloRness/Gauge/ASTM ached 0 Steel C Plastic 0 stainless Steel 0 Other <br /> Grout Seal Deptn tl U Neat Cement(94 Ib bey/610 go/weter) 0 Sand Cement souk mixfT gal water <br /> 0 Bentonite(201%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fell 0 Other C Rotardant l Accelerator(name) <br /> Prbam Installed By 0 Driller 0 Pump Contractor 0 Other <br /> n Con croto PodestaI ODimenalone:Width H Len Ih tl Thlok In U Christy Box 0 Stove PIP0 <br /> SUM► Submersible0 Turolne 0 Other HP " Pum Se tt Standing Wator Lovol R <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 /> MINIMUM A8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(208)963-7697 <br /> SIGNED c i �J4 TITLE DATE <br /> ,9 <br /> k vUlAj Z2016)h�Ec� Iv <br /> q/YT 1'14 <br /> /yF�'T <br /> EP RTMENT U E ONLY <br /> Appllcvllon Accepted By- " Dale Aroa_l� Employee ID# <br /> Grout Inspection By Date (] SPECIAL We11 Permit <br /> Pump Inspeclion By illi � At v) Date ) i 0 WAIVER Reoelved <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENT$ <br /> PE SC Receivsd Amount Date Permit! Invoice#� Well ID# <br /> Cod B Into ash R ml d 9ervJceRe ucatu <br /> / 1L <br /> CHD 47.00 rr/Nd Mate <br /> WE:L iPUMD OER MIT <br />