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T +cwt 5Lu,, 3-2-h fb� <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENWRONMEMTAL HEALTH DEPARTMENT 1868 EAST HA TON AVENUE-STOCKTON CA96205-(209)458-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)/953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB Aminiss z"(.+L3 C 13,-,1 /ntea./ CRYZP CL LI <br /> CROSSSTREET LCCIK-C �RS/ APN OSS-3A0-0g PARCEL S=!L4 .L LAND USE APPLICATION <br /> C) <br /> # <br /> OWNER NAME Li(y ul C 4- PHONE <br /> L <br /> OWNER ADDRESS Wig! Pe w-IL' AVC CRWSTATEZP 9/PCV y 6/1 9svT�.L <br /> CONTRACTOR p -/ .�J LI[ Q ��P���HOOpNE ."!-/]3(�7-3 A& <br /> CONTRACTOR ADDRESS r90�dT Z1Td4s�//G/ W� CMISTA P 4P CA 99-410 <br /> SUBCONTRACTOR A40 PRONE <br /> SUBCONTRACTOR ADDRESS TTTT Cm/STATE/Zip <br /> LICENSE -57 ❑C-01 ❑D-09 ❑Other NUMBER (O(v4UL Eiu RATION DATE G 3 <br /> DOMESTIC WELL SAMPLING:[)General Mineral/Coliform Bacteria(4391)pDibromochloropropane(4392)QA senic(4393) <br /> INTENDED USE ❑DomeatiUPrivate ❑lnigalbNAgricullural ❑Industrial ❑Water Quality Monitoring UISGISampling/Characterization <br /> ❑Public Water System <br /> IfulRner4 mmQ r We.swem ems a arRa u <br /> TYPE OF WORK ❑Naw Well ❑Replacement Well ❑Wall AllenatbNModilNalion ❑Other <br /> ❑Monitoring Wells) #ofwelis ❑Soil Bonng(s) sdmnPOP Wectechnicel �, •eewaps <br /> ❑Out-Of-Service Well ❑Ou140f-Service Well Renewal ❑Cross-Connection Repair <br /> LJ NEW Pump 0 Pump Replacement L]Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ®Auger ❑Cade Tool ❑Push Print ❑ Other <br /> Proposed Well Depth /0-JS R Excavation to-8 in diameter ❑Open Bottom ❑Gravel PackiGrevel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameterin in Thickness/GaugWASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth_ft ❑Neal Cement(94 It,bag/5-10 gal water)(( m <br /> ❑Sand Cl ent sarin mum gal water <br /> ❑9entona90e(20%solids) Wher 1! B <br /> L Iy Ass/ V.Id-106, -19J <br /> Grout Placement Method ❑Pumped ❑Free Fell ❑Other ❑Retardant/Accelerator(name) <br /> EjgL3j& Installed By ❑Ddller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑1lmensions:Width_it Length ItThick In ❑ChristyBox ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set 9 Standing Water Leve R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 /> MI MUM 24 HOU D CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.77697 <br /> SIGNED 7mE� r�l Ili+ MOM(IIOY DATE rr2-)h 2 <br /> �,D♦Fi 'ARTMENi 8 ONLY ��-����p(// <br /> Appliwldn Accepted ,' Date 7/ ( Area Employee ID#Of(O <br /> Grout Inspection By Date ❑ SPECIAL Well Pemit <br /> Pump lnspecoon By Dale ❑ WAIVER Received <br /> Soil Boring Inspect By Dale Constructed Well Depth h <br /> COMMENTS kir mol 11 r3 <br /> PE Sc Received Chaoldll Amount Date Pa. Invoice# Well ID# <br /> Codes Into By Cash Remitted ServiceRequest# <br /> Z 50 I -. °' <br /> Iz 1-7 601 <br /> E104108 W111e WIIL RAMP PERMIT <br />