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WELL/PUMP PERMIT <br /> I, <br /> SAN JOAOUM COUNW EhhfRONAWffAL HEALTH DEPARTUM► 1868 EAST HALELToN Awma-STOCKTON CA 05205-6232(209)468.3e20 <br /> NON-REFUNDABLE PERMIT wwws ov.or lehd EXPIRES i YEAR FROM DATE ISSUED <br /> JoeAooRess 3501 Lohnian Road arar Tra`Y X g <br /> 725-02.461 PARCeLS¢i13.5Ac LAmDUs6APPOcAnONM 's <br /> CAoss STREET Ahem Road A/PN <br /> OWNER NAME Daniel Hepiern 1.�Q C dio,-Ie PROW 209-814-0564 + �� <br /> OWNER ADCRW e70 Puts.row /1��'r ' CnYf3TA7E2!Tracy/CA/e63T/ p <br /> CONTRACTON 1 <br /> �/VGd� 4iQv+s1'�rt Q s��Tft PNOM OS` /� <br /> cON1RACTVR AooaEss 1 SyA R oa seiyel r�KVr-' "e' 111YISTATd2P CA/95320 <br /> SueeONTRACTORfCONauLTANT CTE CAL,INC. pyrpM(211Q)5431799 <br /> SWCONTRACTOR/CONSIA.TANTADMies 4230 Kiernan Ave.Suite 150 CIr/STA MODESTOICA/85356 <br /> LWWU &G57 0 C-61 0 D49 Othal NUAMP E70-161T ExPIRAnoM DATI 113 1/;zo/�7 <br /> :2 <br /> BILLING PARTY: DOWNER ❑CONTRACTOR 6k SWOWRACTOR/CONfkTANT <br /> DOMESTC WILL SANPUNG:D General Mineral/Coliform Bacteria(4391)D DibronwchlOropropane(4392)D Arsenic(4393) <br /> fel NDED UTE 0 DomestldPMate 0 lnigatloNAgricuramal O Industrial D Water Quaky Monttortng B SOII$ampllrtglCharactartzadon <br /> D Pubic Water system trvarar Syrtan Nave coma Noma of ph".N.~ <br /> s dehRM tan Onnr. <br /> TYF6 Or WORK 0 New Well 0 Rep Gement WNI 0 Well AMatioNModi dead fD Other a abamtip <br /> 0 Monitoring Wel(s)_#of eels 0 Soil Bming(e) softtodops R Gee bechnioel 1 <br /> 0 out•Of-Servke Wall O Out-0bSavlw Wel Rene of O Crop-Connection Repair <br /> O New pump O pump geAcemem O Pump Repair D Raise Wei Casin <br /> L CONSTRUCTLON <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 4 Auger 0 Cabis Tod 0 Push PoMt 0 Other <br /> Proposed Well Depth R Eccwation 6 In diameter 0 Open Bottom D Gravel PacklGraval Size in diameter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth R <br /> Well Casing DiameW_N ThldatesslGauge/ASTM SrhW 0 Steel ❑Plasdc D StainlessSteel 0 Other <br /> Grout Seal Depth R B Neat Cement(94 D be26-c0 gni WSW) 0 Sand Came t $ack mbd7 gal wotW <br /> 0 Bentonts(20%so1Hs) 0 Other <br /> Grout Placement Method 0Pumped •Free Fal Otiter r ORetardantIAcCelantfor(name) <br /> Installed By D Driller 0 Pump Contractor 0 Other <br /> ❑Concrete Pedestal DIXmenslons:Width R N R Thick In 0 Chet Box O Stove PIPs <br /> Lptmle D Submersibleo Turbine O Other HP Pump-141--ft Standing Water Level R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARIB7 THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RUMS 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 /> MIININI_UNI 48 HOUR�ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2D9)953-7697 <br /> SIONEO /n ,� 17/L�6z�- Ta+a�GeO109 st DATE 071272020 <br /> TF El JAIT T A C H E D <br /> s <br /> III <br /> O <br /> / O <br /> S G4•A R T M E• • e e q L Y Area Employee IDC <br /> Application Aoupted By_ Dal, V" <br /> Grout Inspection By Date ❑ SPECIAL Well Peffnit <br /> Pump Inspection By tae ❑ WAIVER Received <br /> Sol Boling inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Recelvad Checlo Amount Date PtnnlC Invoice Well 00 <br /> Codes Info 3V Cash Remitted Service RacUesti <br /> r <br /> ISO _c 11--1126A)WIV065 16 <br /> stDa.se wants <br />