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WELUPUMP PERMIT <br /> RAN JDAGM CoulIN EWAR011MBITAL HEALTH DEPARnew 1 e66 EW HAn LTON AVENUE-STOCKTON CA 95206 6232(209)46"20 <br /> NON-IZEFUNDABLE PERMIT www.s- ov, ehd EXPIRES 1 YEAR FROIJ <br /> DATE ISSUED <br /> [J-06DDREea • I. CITYIZIPs /1 /{ 766 S7ARM Iia LArm UsE AvvucAT*N A <br /> R NAME /vimAkwI/) 1y �G_�y+ In NONE���/R AODRE8a J S E/ ,AQ� IT178TAT ftc�I�rts�,A A f9�Z <br /> CONTRACTOR C i-w • ,1 A6/i eeJ< --i A PHONE 9�I YSS-'yll.i ext, �Z <br /> CONTRACTOR ACOREs6 I/' 11l 4 <br /> SUBCONTRACTDRICONBIATANT — A PNGNE L14)7t 9-879ff <br /> SUBCONTRACTOWCONSULTANTADORE6S 15-149 nI� CmtSTATEIZPI/jxI&I ICA/ 9-5-120 <br /> LICENBE 11067 D C-61 D D-09 0 Other / Numm JrZ 7 EIwnATm DATE ��J✓r/Z O�0 <br /> BI LING PARTY: ❑OWNER O CONTRACTOR ��> NIRMCTOR/CONSULTAM <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)D Arsenic(4393) <br /> IN_N0 Use ❑DomestkJPrlvote D Inige6on/Agdeuflurel 0 Industrial 0 Water Quality Monitoring Otoll SamPling/Characterkation <br /> 0 Public Water System <br /> N Clflennt from Qaar. Waiter SylMrnNma CONW Nero m Phoma NMter <br /> _ 1 <br /> En OF WORN 0 Now wan D Replacement well D Wag Aleration/Modlncation 0 Other <br /> D Monitoring Well(s) tt of wells 0 Son Bodng(s) s oib f�o° geotechnical_1 Q 8 W bcrinpe <br /> 0 Out-O&Service Well D Out-OfServlce Well Renewal D Cross-COnnactlon Repair <br /> CpNvw ❑New Ptmn-.,,_0 Pump Replacement 0 Pump Repair D Raise Well Casino <br /> Drildn g Method Mud Rotary ❑Air Rotary 6f Auger 0Cable Tool D Push PON D Other — <br /> Proposed well DePth/StaSD I Exceve6on yam_In diameter D Open So6om ❑Grovel P"WGrevel Size M d*noter <br /> D Conductor Casing In dienwter / ConductorCaeing Depth R <br /> Well Casing Olemeter In Thleknese/Geuge/ASTM Sehed 0 Steel D Plastic D Stainless Steel 0 Other <br /> Grout Seal Depthi s_so I Aeat Cement(94 1b bag/rtegal wateq 0 Sand Cement sack mix/7 get water <br /> G Bentonite solids) 0 Other_ <br /> Grout Placement Method ped roe Fell 0 Otter D Retardant/Axeterotor name) <br /> PEDESTAL Installed By ❑Drifter D Pump Contrardor ❑ Other <br /> D Concrete Pedestal DDfrn alone:Width it Length it Thldr te ❑Christy Box D Stow Pipe <br /> P P 0 Submersible0 Turbine 0 Other HP Pump Set R Standing Weber Levret fl <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. 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 H U AD CE NOTICE REQUIRED FOR INS TIONS-PLEASE CALL(209)953-7697 <br /> -�� 3 T I Zoi9 <br /> SIGNED TITLE �. DATE <br /> 1 <br /> o° <br /> FN10' �0�0 <br /> Ty DFpq��O�N� <br /> 41 <br /> AMENT US O L — <br /> Appeeation Accepted By ate <br /> Area <br /> Employee <br /> ID# <br /> Grout Inspection By Date 0 SPECWI-Well Permit: <br /> Pump Inspection By Date ^ E) WAIVER Received <br /> Soil Boring In It By - pe structod/W_ell Depth.-_.___ g <br /> COMMENT ]-0r/h <br /> i PE SC ReceivedAmount -- ——4—--- <br /> as Info tm Service watt) hof a won oe <br /> I <br /> END4sa enrrmha ------- ---- – — <br /> W9LIPtaIPP6RAfT <br />