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a� <br /> WELL/PUMP PERMIT <br /> SAN JOAOtAN COUNTY ENVIRotmwrAL HEALTH DEPARTMENT t88a EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468.3420 C <br /> NON-REFUNDABLE PERMIT www.s <br /> LAI fp, <br /> www.sjgou.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> .1013 ADDRESS :/7 ajk4 Cm/LPL � <br /> CRn.SS STREET /V t jT/���PN (�(� -/o � PARCEL S12E6 �,�LAND USE APPLw-AnoN 0 p o <br /> OWNER NAMr fJ _. P 1_ PHONE <br /> ADDRESS <br /> OWNER ADDRESS � ' .. iCITY/STATEIZIP 14/f7(/ <br /> /f7(/V/ %, <br /> PHONE <br /> CONTRACTOR �._ ��✓/ -57 <br /> '1110 <br /> ofCONTRACTOR AODRF.SS F CITYIISTATEIZIP <br /> SIRICONTRACTORfCONSULI ANT L <br /> y <br /> PHONE rte— <br /> SUacownACTORICONsULTANT ADDRess CITYISTAT'EIZIP �' <br /> LICENSE 01-57 ';-�I 11 D-II<3 U nthet NumRER owY/Q <br /> 46 EXPIRATION DATE— _ <br /> BILLING PARTY: :OWNER OVONTRACTOR SURCONTRACTORICOMIILTANT <br /> DOMESTIC WELL SAMPLING: eneial MinerallColiform Bacteria(4391) bromochloropropane(4392) Arsenic(4393)pgy 9,g. ' <br /> INTENDED USE stirlPrwate r7 IrngationlAtIrtcultUral n Industrial Ll Water Quality Monilonng U Sal SamplinpO:para <br /> Q <br /> PUlllic Water System _ <br /> x rolrerwn Man Owns, WNM SrNem Nome r:m+ad Name a VMme r rr ' <br /> TYPE OF WORN n New Wall WReplacerrienj Well U VJL1 AlterstbnlMochkation D Other— <br /> ­nr JO <br /> 11 Mor ilolillg VJell(s) C of wets 1.1 Soil Bonng(r.) e M Eorl- 11 GeotechrliCat Atj <br /> 1.1 Out-Of-service.Well 0 00-Of•Service WellRenewal Ci Cross-Connection Repair�ir�( k�' <br /> MINew Ptnlp D Punp RCglacerlten! D Pon <br /> p Repair _--._ D.Raise Well Cali BAR <br /> WELL CONSTRLif—rio AFF <br /> Drilling Method PoMud Rotary n-y�Atii�r�Rotary U AUger O CaUle Too) U P1rsh Point D Other J <br /> Proposed Well Deplh—,Z!;ej� l(— Excavation j!�L in diameter U Open Bottom 4kAfaVel PacldGravel Size !Y in diameter <br /> I Conduclur asing in dlarnelei l Conductor Ca�singa Depth 11 —'T <br /> Well Casing Diameter in ThiclulesslGaugelASTM Soled jCZA;W <br /> ! V Slee) 401151astic D Stainless Steel D Other <br /> Grout Seai Depth it L1 Neat Cement(94 M bIV5.10gal W&w) r0 Sand Cement sack mix17gal water <br /> 46entonse(20%solids) O Other _ <br /> Grout Placement Method tARped D Free Fall U Other 3 Retar and I ACCClefalor(name) <br /> PEDESTAL Installed By D Drlper"Pump Conlredor r1 OIMv — —�j� <br /> D C ncrete Pedestal D mentons:Wldth It Length 11 Thick n U Christy Box U Stove Pipe <br /> PUMP �SubmersibleLl Turbine C Other_ HP Pump Set 1t Standing Water Level_�y_1'R' I <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI'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 /> MI O ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)/953-76 / <br /> `97n;A <br /> GIF TITL2_&A/� DATE ! �7/ 7 <br /> rr <br /> 01 <br /> e <br /> - <br /> EPARTMENT USE ONLY <br /> (�f <br /> Application Accepted BY Date Areaoyee IL�II�!`1 ' <br /> Grout Inspection By_ Dale VIIIIAL Weil Permit <br /> Pump Inspection By Dale �' WAIVER Received <br /> Sal Bor ng I 0041 By Date CDllbtrllcted Well Depth it <br /> NT <br /> PE SC Received Ch Amo"nf Dal Permit; Invoice A Well IDK <br /> Codee In Keil Remitted _ ServiceRegueetf <br /> 0 <br /> eltlF ryttfAla -- <br /> WEL I,/PL41P PERIYT <br />