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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAzELTON AVENUE-STOCKTON CA 95205-(2091466.1420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ra <br /> JOB ADDRIM' <br /> CRY/ZIP 7 <br /> CRosSSTAPN�j-I40 f 1 D <br /> %IO PARCEL SIZE 1 `S L7 LAND USE APPLICATION# _ Q° <br /> OWNER N <br /> PHONX OWNERACITYISTATE77JP XXM - �j1((��CONTRACPHONE (/-N <br /> CONTRACTOR ADORES. I CITYISTATE/Z1P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYIS(`�TAATEJZIP <br /> LICENSE C•57 D C-01 0 D-09 0 Other NUMBER EOf 64 L2 EXPIRATION DATE <br /> DoMEsTm WELL SAMPLING:0 General Minerat/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domesuc/Privale XmIgallonlAgricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> 11 different Iron Omer. Wel.System Nem, Conlact Name or Phone Number <br /> TYPE OF WORK ZN.w Well 0 Replacement Well 0 Weil AllerallonrModincallon 0 Other <br /> 0 Monitoring Wallis) #of Well. O Soll Bodng(S) aorbodnoe 0 Geotechnical sallwrirgs <br /> a <br /> 00 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> Pump Replacement 0 Pump Repair 0 Raise Well Casing❑NSlceWell <br /> WELL CONSTRUCTION <br /> Drilling MathadXMud Rota O Air Rotary U Auger O Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft 6 cavallon 4`In diameter 0 Open Bottom Gravel Pack/Graval Siz6At_WIn dlameler <br /> O Conductor Casing In diameter I Conductor Casing Depth It <br /> Well Casing Diameter In, Thickness/Geuge/ASTM Sched_:UD 0 Steel Plastc 0 Stainless Steel 0 Other <br /> Grout Seel ''Dffepth ft 0 Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mlxr7 gel water <br /> Benlonit (20%solids) 0 Other <br /> Grout Placement ethod umped 0 Free Fell 0 Other O Retardant/Accelerator(name) <br /> ED TAL Inshiled By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimonslons:Width ft Length ft Thick in 0 Christy Box O Stove Pipe <br /> PDMP 0 Submersible0 Turbine D Other HP Pump Set R Standing Water Level ft <br /> I HEREBY CERTIFY THAT I 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. I 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 /> MINIM H A NOTICE REQUIRED FOR INSPECTIQN�S:I�LEASE CALL(209)D53-`97 <br /> SIGNED u W P►�(, -�J �I" <br /> T T <br /> �vl T <br /> 101 <br /> TY <br /> E T <br /> DEPARTMENTU E NLY <br /> Codas Info Cash Remitted <br /> Application Accepted By G �f Date �' �3 0 Area 5 �C� Employee IDff a <br /> Grout Inspection By Dale ❑ SPECIAL Well Permit <br /> Pump Inspection By Dale D WAIVER RBCeIVed <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permitl Invoice 0 WBII IN <br /> Se Ic Re ueetfi <br /> EHO 43-M BMWs /��// 2'-'7 �[�C WELLIPUMPPERMIT <br />