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TYPE OP WORK I Now Well I Replacement Well Well Alter atioreMoilincatinii Other <br />I Monitoring VVell(s) It o) wells " Soil ElnringIS) 9 Goutecistieal <br />(ATI-UI-Serme WOE Ord 0113eivice Well Renewal Cross-Connection Repair <br />Nev. Pump P.uDp Replasement X Ptallp Rep, Reiss. Well Casing <br />,VALT._ConsTixpeT1011 <br />Chilling Method A Mud Retaiy I Ax Notary 11 Auger II Cable Tool _ Push Peng _ Other <br />Proposed Well Depth n Excavation in diameter I Open Bottom I Gravel PaC.IGraVel Sae or diameter <br />Cenducter Casing in &model Cultduclut Casing Depth II <br />Well Casing Dorne.ler in ThiclinessGaugeiASIM Scheo I Steel Plastic Stainless Sleet Other <br />Grout Seal Depth II . Neat Cr:Meld (94 lb Lavb 10 gal watt,' I Sand Cement sack rnix•i gal water <br />BenIonse OD% xelvist I Other <br />Gioul Placement Method _ Pumped ...I nee Fall Other Ii Rolm dant I Accelet alto tikm,) <br />P 6REA1AL Installed By Driller Pump C.ontiactur <br />" Concrele Pedestal mgimensiops width <br />Other <br />ft length II Thiel. Christy 005 n Stove Pipe <br />I INTENDED Usc X Ilamestie.,Private 1 IrrigatiomAgrieultural Industrial - Water Ouality Moniloung - Soil Sampling/Characterizahnn <br />Rube Water System <br />I-1 r.,..,,16,, o...,, vr :NJ., ....,•,.., "L. p• <br />,.7 6031 Della Ave <br />ecyQIA 91314 <br />WELL/PUMP PERMIT <br />SiINJOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1569 EAST HAZELTON AVENUE STOCKTON CA 95205-6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.s. ov.orOtptid EXPIRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS <br /> 0881 Delta Ave bJ De Ctry/Z•T I race/5304 <br />Ross SyReo Tom Paine Rd APN a3103:0? 0' PARCEL SIZE I LAND USE APPLICATION ii <br />OWNER NAME <br /> Greg Foinbo (NONE MR 481 74:27 <br />OWNER ADDRESS 5AMI: <br />CONTRACTOR pella Pump lin:. <br />011TRACTOR ADDRESS 64133 C3iit°"" 3' <br />LIT Y/S TATE/DP <br />PHONE <br />Cm/STATE/2m 93203 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />K.:ElISE • C-57 IC C-6I 0.05 Other <br />CITY/STATEOP <br />NumeEe 1055434 EXPIRATION DATE 73120::: I <br />PHONE <br />BALPA: PAM v. OWNER CONIITACIDR SUBCONTRACIoN/CoNSUL TANI <br />• <br />Demesne WELL SAMPLING: I General Mineral/CW[1.am Bacteria (43.9 I Bibromoehloropropane (4392) 7 ArSene OM) <br />12..)05_, X SuRimersitite f urbme . Other HP ' Pump Set 1 ' II Standing Wale, Level It <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 IHF CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAI i AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Grout Inspectscn 13y Dale I SPECIAL Well Perrnil <br />Pump Inspenicri By cto.‘,C. C Vevel 0.---141 1/4. Date 1-k ((b,Oi. I WAIVER Received <br />Soil BUN rj 111:411,111.111 By Dale Consli acted Well Depth _,)romultS <br />PC <br />Cortes <br />----U' <br />SC <br />Into 2 A <br />Received <br />Date <br />,7,;V19.-- <br />- . <br />Amount <br />Remilted <br />Period! <br />mice R 1051 It Invoice Tr Well Oft <br />OS-0 , hY :swim NiMIHELF111101ME <br />II