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WELL/PUMP PERMIT <br /> SAN JO - ENNRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96206-6232 (209)468-.1420 <br /> NON-R LE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FRoM DATE ISSUED <br /> JOB Mitn 4d. 1$485 cITY/zIP Repo v% 9 S36b <br /> �j <br /> cRoss8TtiEEi Cw�ro)�aN APNZ�Is�iib��TI� PARCELSIZE IN fo LAND USE APPLICATION# p <br /> ER <br /> OWNNAME &^"V �ficriTnrg koolhow PHONE 3n7-Y-1Z.4/ <br /> O..A.Mn II-tAJOW OA`S _T.>t• _ CITYISTATE/ZIP 1 41!*41 lw�f 9S1ib <br /> CONTRAeMoR MastIIs r •is PHONE 6 2L'19 Lb <br /> coornuM oRAngtEaaA 16trj CITYISTATE/ZIP/Mr/ef>fo�('a 9S3S7 <br /> 7S1,19CONS#A67eWCOWtIITANT PHONE <br /> Suet wm" . GomsmTAMT AODRES6 CITY/S'rATEIZIP <br /> U D-09 U Other NUMBER(6168622- ExPiRATION DATE <br /> LICEN6E �C-67 D C-01 <br /> BCLING PARTY, rI OWNER CONTRACTOR I.SUBCONTRACTOR/CONSULTANT <br /> DomesTe:WELL 8AmpLA19:t I General MlnereVCollform Bacteria(4391)I!Dibromochloropropane(4392),i Arsenic(4393) <br /> �yp�,g Use Dop—lkJPrivate 0 Inigetion/Agnculturel O Indusidal 0 Water Quality Monitoring 0 Soil Sampling/Charecterizatlon <br /> 0 Pubk Water System <br /> EMrarlr Aeel Owren Water Syetan Nrne Canted Name or Phone Number <br /> r=Cr Woa Wal 0 Replacement Well 0 Well Alterason/MDdi6callon 0 Other <br /> D Monlleft WOWS) •of wells 0 Soil soft(s) Y or bodngs 0 Geolechnical If o1 bodnga <br /> 0 04-01-64e 00 We! 0.Out-W-Service V.fell Renewal 0 Cross-Connection Repair <br /> D Now PwM 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> MLLCONSTFACIM <br /> Orgling Madlod XMW Rotay 0 Ak Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Wap Deplh 0* Il Excavation 111'1 _In diameter O Open Botlom V Gravel PaddGrevet Size in diameter <br /> O CalduobLr Casing In diameter / Conductor Casing Depth fl <br /> WON Casing Owns r i M TNderosslGauge/ASTM Schad -L01)— 0 Steel W Plastic n Stainless Steel 0 Other <br /> Grout ideal Deplh.'j„` 0 0 Neat Cement(94 Ib baW5-10 gal weterl 0 Sand Cement sack m/x/7 gal water <br /> Afto onpa�� �W%s'ol'ids) 0 Other <br /> Grout PhwwraM Matlred flpvr0 Free Fail 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL bsW"ey DDrller X Pump Contractor D Other <br /> D Cen rsb POdoetol DDImemlons:Wldlh R Le Ih ft Tldck In 0 Christy Box 0 Stove Pipe <br /> D SubmwsIbleLl Turbine 0 Other HP Pump Sel R Standing Water Level tt <br /> 1 HEREBY CERTIFY THATA 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPOMAT1ON LAWS. <br /> AAI 4/HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> StaNee TITLE Otrvw/ DATE <br /> J <br /> LJ <br /> Q <br /> U <br /> ,--"OAItTMEMT?2�USE <br /> J-ONLY <br /> AppttcedonAcc1lpbdOr I!� <br /> SSW IF _7_7 <br /> ! / NM E Yee ID# <br /> GroutFropedbnBy Date PECIA Well Permit <br /> Rump Inspection By <br /> Date 1 WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received r,hac Amount Date Permltl Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> 6 s 00u Q <br /> WELL/PUMP PERMIT <br /> EHD�J-ab dllrtelg <br />