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Apr 29 19,03:01 p p.1 <br /> - WELVPUMPTERMIT <br /> SAN JOAOUIK COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 18"EAST HAZELTON AVENUE-STOCKTON <br /> CA 85205-(209)168.3470 <br /> NON-REFUNDABLE PERMIT CALL 209 1953.7697 FOR INSPECTIONS EXPIRES.l YEAR FROM DATE ISSUED w <br /> r ,j <br /> - CITT/Z1► D - ��. <br /> Joe ADDRESS /JT I / <br /> APN02-t 4-0-(3PARGELStZL��LANDUSEAPPUrATWN# <br /> C ROSS STREET PNONE <br /> OWNER NAME <br /> N CITY73TATE21P <br /> OWNERADORESS PNONFq / j`- •'/`l Y <br /> 7 4J <br /> CONTRACTOR //{Ii'►(7t {fin / �/Jy'/�' <br /> CON RACTORADORE55 CITYISTATEIZIP <br /> PtaNE 1J V <br /> SUBCONTRACTOR - <br /> -C TYISTATEI7JP <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE G57 0 C-61 J"D C Other Nu0SAz" EzPatATION DATE . <br /> DDIrEs1K WELL MPLING:D Gen nal MirieradColiform Bacteria(4391)D Dibromoehloropropane(4392)0 Arsenic(4393). <br /> 1!!� <br /> IrrigaliorJAgricultural 0Industrial DWaterQuokty Mon2oring 0 Soil Samloiing/Charac:erizalidn <br /> tem WN.r Cord00t Nam.m Fh..Nu.6.1r. <br /> TYPE OF WORK )1 VYeI l 0 Replacement\Nell O Well PdterstionlModifiealion s or b0alOther s a oo nz• <br /> 0 Monitoring Wells) tel Of wells O Soil Soring(s) 0 Geotechnical <br /> Ou'-Of_service Well D OuttX-Service Well Renewal O Cross-Connection Repair <br /> New Pump O Pump Re IacemerR 0 Pum Re air 0 Raise Wek Casin <br /> WELL CONaA1UC1 Nle <br /> Drilling Method Pi Mudla O'Air Rotary :?Auger C Cattle Tool O Push Pant 0 Other <br /> Proposed Well Depth 0{� It Excava,Ion k;l,— in diameter ❑Open Bottom D Gravel Pack/Gravel Sive In diameter <br /> J Conduc Casing in diameter ' Conductor Casing Depth H <br /> Well Casing Dlangler n TtrcknesslGaugelASTM Schad ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal D plh it 0 Naat Cement(94 fb bag15-10 gal water) 0 Sand Cement sack mizfl gal rater <br /> ;Bentonite(20%solids) O Olhei <br /> Grout Placement Method D Pumped 0 Free fall D Other D Retardant/Acceietalor(name) <br /> DE TA Installed By. D Driller D Pump Contractor- 0. Other <br /> L 0 Cancrate Pedestal 001mensions Width It Length kTlrck in O Christy Bow J Stove Pipe <br /> Submersible 0 Turbine 0 R e <br /> Other HP Purnp Set - Standing Watr Level <br /> Pump <br /> ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL Bl: GONE IN ACCORDANCE WITH SAN <br /> JOA IN COUNTY ORDINANCES, STATE LAWS.AND RULES AND REGULATIONS. 1 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 /> WORKE1a.pDMPFNSATION LAWS. <br /> M K Jef V OTICE REQUIRED F R NSA IQ S-PLEASE CALL(2 )953- 19117, <br /> r i TI DAT <br /> SIGNED ) 1r <br /> T <br /> r <br /> DE ARTMENT SE N Y <br /> +' 2� Area^ Employee IDli <br /> Application Accepted By r I' <br /> Grata Inspection By Date ❑ SPECIAL Well Permit <br /> Punlp.lnspection By <br /> Dale - ❑ WAIVER Received <br /> r <br /> Date Constructed Well Depth <br /> ft <br /> SBoring Inspection By <br /> COMMENTS <br /> Amount Dale Permit/ Invoice 0 Well ID# <br /> PE Sc Received Arnou <br /> SarvicoR ��stR <br /> Codes Into B Cash Re Itled <br /> 4 1 <br /> � 2 J <br /> 5� <br /> VVELUPUMP PERMIT <br /> Elrc 43-06 N01116 - . <br />