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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95206 4232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> �JOR ADDRESS <br /> aT—APN�' (/V " PARCELSIZE *LLANO USE APPLICATION a7 L� -q p <br /> IOWNERNAME /��LJ/I�/ r! ,�PN��pIIN� ��`�Q 71O G <br /> OWNERADDRESS A&4/ GITYISTATEIZJP /J/ � <br /> CONTRACTOR _ -Q �r <br /> PHONE L—Z`r(J <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> SUBCONTRACTORICONSULTANT S �i//4�F•hJ�/� PHONE <br /> SUBCONTRACTOR/CONSULTANT AODREsa CITYfS'rATEIZIP <br /> LICENSE -57 11t�-61 rl D-09 U Other NUMBER�RrIA E%WRATION DAVIE <br /> BILLING PARTY: �`��1 OWNER :I CONTRACTOR SUBCONTRACTORIC(N SULTANT <br /> DOMESTIC WELL SAMPLING;I General MineraUColiform Bacteria(4391) ;Dibromochloroproparle(4392), Arsenic(4393) <br /> INTDMD USE olnsticipriv to (1 Irrigalion/Agricullural n Industrial a Woler Ouality Monkoring U Soil Sampli g/Cheraclerization <br /> n Pullfic Water System__ <br /> N Albew t hen DYnar: VMW Syalem Nome Compri Name a Phmre Nurna4 <br /> TYPE OF WORK kNeW WEU 0 Replacement Well n Well AlleralionNodikiihOn n Other <br /> LT Mootot"Wel(s) Is of wells I.I SMI Borings) _ s a bO 0 GeDledmkal e of borings <br /> U OW-Of-Service Web U Ow-Ot-Servicr.Well Renewal U Crosti-Connectlon Repair <br /> rI--- �ew PHmp [1 PtnT Replacement 0 Purp Repair O Raise Well Casino <br /> WELL CON sTr�T N _ <br /> Dr't rg Method ❑Mud Rotary rl Air Rotary U Auger n Cable Tod O Push Point n Other <br /> Fr osed Wall Depth2—Oe(Qb Excavation Z r- in diameter D Open Bottom 'IrGravell Pack/Gravel Size In diameler <br /> i <br /> U Caxluc(or i sing In diameter I Conductor Casing Depth fl <br /> ell Casing r.)1ameter_jJL2in Tleckrlesa/Gauge/ASTM Sched 4:'—'ZZ1�1 O SteelJylPlastic 17 Stainless Steel D Other <br /> Grout Seal Oepth__y(ga_11 (1 Neat Cement(94 lb bag/5.10 pal water) U Sand Cement sack mi rf7 gal water <br /> I)II0eenIonite(20%soNds) U Other <br /> ou <br /> t Placement Method 0 Pumped U Free Fan 0 Other Cl Retardant/Accelerator(name) <br /> TA lnstatled By ❑Driller ,JSIPump Contractor n Other <br /> 0 Concrete Pedestal ODlmensions:Width s R Length tl Thick In U Christy Box U Stovepipe <br /> P &bmersibleD TUrbine 0 Other HP -_-Pump Sol fl Standing Waler Level <br /> EREBY CERTIFY THAT I HAVE PREPARE[) THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> pQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> RENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE. LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> RKERS COMPENSATION LAWS. <br /> MIN�U ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953 1? <br /> I�NED� r TITI-15� L�` DATE 1 ! <br /> I I <br /> ———————— ——9 <br /> L ►�!/� <br /> YP6•YPP�--.rt:- T D E N T U E N L V <br /> Application Accepted Sy Dale jay[��� Area Employee IDAe�+�`+��"-� <br /> Grout Inspect on ey_ Dale PECIAL WBII Permit <br /> Pump Inspection By Dale I WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received heckllAmoum Permltl <br /> Code Into B ernitted Dole Service Request A Invoke It <br /> -VAN� 7TY1 <br /> w q <br /> •-ri.�J�[I MlrlOin <br /> MIT <br />