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WELUPUMP PERMIT ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 Bee EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46"20 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXXPIRES 1 YEAR FROM DATE ISSUED Joe ADolTess Crry/AP QV _�p_pcp r�1r� o CROSS STREET 5r_'WNK •APN PARCEL S� • 1 J LAND USE APPLICATION i'F OWNER NA PHONE ME ,.1 OWNER ADDRESS V\ - CRYISTATEZP CONTRACTOR PHONE CONTRACTOR ADDRESS CnY/STATEZP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS Crry/STATFJMP LICENSE C U 2-57 ❑C-61 ❑D-09 ❑Other NUMBER L EXPIRATION DATE�' '2-1 DOMESTIC WELL SAMPLING:O General Mineral/Col'rform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) INrENDEO UsE DomesUcfPrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring D Sol]Sampling/Chareclerization Public Water System If dererare from Owner. Wsler System Name Contact Name W Pt.-N=b-r TYPE OF WORK ❑New Well Replacement Well ❑Well AlterationlMDdiflcation ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a of bongs ❑Geotechnlcel s of boring* ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair D Raise Well Casing Drilling Method Mud Rote ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth R Excavation�_In diameter ❑Open Bottom ❑Gravel Pack/Gravel Size In diameter ❑Conductor Casing In diameter / Condy -sing Depth It Well Casing Diameter IL In ,Thlckness/Gauge/ASTM Schad I4Steel ❑Plastic ❑Stainless Steel ❑Other Grout S"I Depth LOU ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mW7 gal water kenlonit (20%solids) 0 Other Grout Placement Method Pumped D Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal❑Dimenslons:Width ft Length ft Thick In ❑Christy Box ❑Stove Pipe PUMP O Submersible❑Turbine ❑Other HP Pump Se(_ ft Standing Water Level ft I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR A VANCE NOTICE REQUIRED FOR yI�N$1PvEYC"nONNS*-PLEASE CALL(209)953-7697 SHED TRLE U I I W I 1 V T.s 1 V Vj DATE 04. j It Nk_N qpR F�VFp 1 7 j�qQ Ns1QZ, Opt p N21y FNT� LLLLJ 1k. . MENT U E �Nr�LY Application Accepled By Date `-y Area Ernployee ID# . Grout Inspection By Date D- PECIAL Well PalTteft Pump Inspection By Date 0 WAIVER Rewlved Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ChscW Amount Data Psrmw Invoice# Well 100 Code lato Ain h Remitted I ^I I RemiceRsqMts it i WELL IPUMP PERMR Er+o4sDe 'e�otns �IM 1'�X�-� f'�'l .