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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AvENuE•STOCKTON CA 95205-(209(4883420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS W�AGCrTYZP 3 <br /> �3. > <br /> CROBS STREET -APN201- 100-0130 PARrsn //C�tE��L 912E LANG USE APPLICATION � <br /> OWNER NAME W PHONE <br /> OWNER ADDRESS b0KCrrY/STATE2IP \Jl/� <br /> CONTRACTOR :NmrillimZ. <br /> PHONE <br /> CONTRACTOR ADDRESS CrTY/STATEr0P. q <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEMP <br /> LICENSE -57 0 C-el 0 D-09 O Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: [General MinereVColiform Bacteria(4391)Dlbromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE DOmesbc/Privale 0 Inigation/AgriaRural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Charactenxation <br /> 0 Publlc Water System <br /> If db%—g*—0— Wabr Syalsm Na cmhru N—a Ph—NumW <br /> TYPE Of WORK New Well Replacement Well 0 Well AReratlon/Modtfication 0 Other A n//C, <br /> 0 Monitoring Wellgw D <br /> Wall(s) 9 of wells O Soil Borins) e b"tW* Geotechnical s d b­ng. E rlI EIV <br /> 0 OW-OfService WON C Out-Of-Service Well Renewal 0 CrossConneCtIon Repair C �D <br /> 0 New Pum 0 Pum Replacement 0 Pum Repair 0 Raise Well Casing <br /> W CN C T <br /> Drilling Method ud Ro 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other 62920 <br /> Proposed Wall I n <br /> pos Depth R Excavation�_In diameter [73 Open Bottom Gravel Pack/Gravel Siz in a AQ <br /> 0 Conductor Casing In diameter I Conductor Casing Depth R HEALT IN <br /> EN�� TY <br /> Well Casing Diameter. In ThIcknesslGauge/ASTM Schad� 0 Steel PPlasbC 0 Stainless Steel 0 Other <br /> Grout Seal ��D[[epth ft 0 Neat Cement(94!6 baWS-10 gel water) Sand Cement sack mixes gel water Q R T to <br /> Bentonite(20%solids) 0 Other <br /> ENT <br /> Grout Placamsn Method Pumped 0 Free Fell 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller O Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODlmensions:Width_tt Length R Thick In 0 Christy Box 0 Stove Pips <br /> P ❑Submersible❑Turbine ❑Other HP Pump Set R 'larding Water 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. 1 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 COMPENSATION LAWS. <br /> MINI O VANCE NOTICE REQUIRED FO�RJNSPEC ONS-PLEASE CALL(209)9(53.7697 <br /> SIGNED TITLE-,((1_(j H/r Dry N�i DATE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By LL41-(211" ! <br /> DateO0 0 Area ' C//� 1. <br /> Grout Inspection By Data r Employee IDS <br /> C1 SPECIAL Well Permit <br /> Pump Inspection By Data <br /> ❑ WAIVER Received <br /> Soil Boring Irope on By <br /> �� 1'' Constructed Wall <br /> COMMENTS l�j �--� x,�Z> ) r Date Depth ft <br /> rY�:M 1r Iry1 r.: FMC �rVWS <br /> PE SC Racelved Chee1W Amount <br /> Codes Into Remitted Dob ServlceeR nest!III invoice R Well IDS <br /> 370 0 <br /> i7 <br /> EHO 41e6 aAt/1e <br /> WELL RUMP PERMIT <br />