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Oct 01 19,03:21 p p.2 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HeALTH DePARTMENT '1665 EAST HZIMTON AVENUE-STOCKTON CA 95206-6232 12JR)46!•3420 <br /> NON-REFUNDABLE PERMIT www.sffiqav-.orq/ehd EXPIRES 1 YEAR FROM DATE ISSUED m <br /> Joe ADDRESS t <br /> DITYIZIP <br /> CROSS STREET "� �N/Y NJ PARCEL SIZ <br /> ELANG USE APPLICATION <br /> ommpt NAmE f yy^r/•/.�"/� PMf7rN�L4Y��/V G/�j/�T�,_���� <br /> C%OIER ACDRESS _ -' 44, 0411'' 46 e7� CITTYYISTATe2R'�/v4 - - <br /> CONTRACTOR PM.DNV CPO <br /> CONTRACTOR ADDRESS alA>>'I4 D CRY/STATEIZIP <br /> SUBCO'ITRACTORICONSULTA.VTMr^ f�I'�� ` },�Cr� 4211/' PHONE r <br /> IS'JBCONTRACTORICONSULTANi ADORESa �/� W�1 —_ C/I�TY//$pTATFJZIP !�n OlzD <br /> ` �•-��35 <br /> �LiceNSE OK-57 ❑C-61 D D-09 D Other NUMBER 710! EXPIRATION DATE <br /> (BILLING PARTY C OWNER O CONTRACTOR D SUBCONTRACTCRICONSULTANT <br /> DOMESTIC WELL SAMPLING: 3eneral Mlner2VCO11forrn Bacteria(4391)0 Dibromochloropropane(4392)D Arsenic(4393) <br /> IuTENpeD i1SE rnestkJPdva:e Olrrigation/Agricullural O'ndustrlal OWaler CIUailly Monitoring ❑SDIi SaTrpllrg/Charactedzatien <br /> . O Public Water System . <br /> 'r dlae—t korr.Owner Kele:Syelem N-" Conrecf Name d Panne rAA,a,er <br /> TYPE OF WORR New Wall 0 Replacement Well 0 Wel AlteralloriModilcatIon 0 Oiher . <br /> rotbmlos+ O <br /> 0`Aartorinq VJeI(s) sot Mels Ll Soil Boring(s) *ofboring, 0 Geelechnicel S�•f] <br /> 0 Oui-Of-Service Well D Oul-Of-Sertk-a Wel Rerewsl 0 Coss-Connecilon Repetr 0 <br /> ew PumD D Pump Re cerne-It O Pump Rap air 0 Raise Well Casino <br /> 1VE L COtW qTIOH f"✓1R Lr/MC <br /> Drilling Method 7�Mud Rota O A'r Rotary O Auger 0 Cable Tool 0 Push Point ❑ Other - ry <br /> I Proposed'TJeil Depth 71 n Excavation fJ Ir,dlametar C Open BolloR Gravel Pack/Gravel Size In of I <br /> O Conductor Casing 'Indlameler ! Conductor Casing Depth. / P <br /> j woll Casing Dlametar In Thick ness/GaugerASTM Sched, zeV O Steel JStainless Sleee O Usher <br /> Il Grout Seal Depth •7D" ft DNealCement(94!dbagv5-f0gelwvlsrt /k�laslic 0�NSandCement /t9r7 —sack mirl7"at water <br /> f O Bentur.!le(20%solids) 0 Other <br /> Grout Placement Mothod kpumped O Free Fail 0 Olher O Retardant 1 Accelerator(name) <br /> r'[D^;TAL Instatted By 0 Driller D Pu'np Contractor D Other <br /> C Concrete Padeslal 001mensIon e:Nlydlh_R LengIh.fITbICk.h 0 Christy Box 0 Stove Pipe <br /> •':br Submersl IeO Turbine 0 Oilier HF — Pump Set P Standing Water Level IF <br /> I HEREBY C TIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> It)^^!+IN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE I5 <br /> Cl.,•.',ENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL i <br /> WORKERS COMPENSATION LAWS. <br /> MI g U NOTICE REQUIRED FOR I P NS•PLEASE CALL(209)95 76 <br /> SIGNED TITIk DATE / <br /> + <br /> _ RTrAENT USE ONLY C� <br /> Application Accepted By <br /> Dale--� Atex E-nployee ID4 J� <br /> Grout Ilrsoecllon 2y Cate vI=_c1AL well Permit <br /> Pump Inspecilon By Dale - WAIVER Received <br /> Sell Bering Insaeclion By <br /> Jateonstructed Well Depth Tt <br /> CO'AME TS <br /> PE SC Received eck#1 AmOU. Date Permit) Involce tl Wan lox <br /> Codes Into B Remitted Service R Uesi ll . <br /> I UD ,3o WPO04-0 i 35 <br /> 5 <br /> 4 } <br /> Vnl'_R-L.NP PERYIrT <br /> ERDd>09 61SI'2+9 , <br />