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WELUPUMP PERMIT <br /> SAN JOAQUIN CouNry ENwRoNMENTAl-HEALTH DEPARTmEw 1666 EAST HAZELTON AVENUE-STOCKTON CA 96206-(209)466.7420 <br /> NON-REFUNDABLE PERMIT CALL 208 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSVIA AM UrzA10N, C lglko <br /> CmILp L. ` 1V 6 `71, V <br /> CROSS STREET — A > <br /> 1 0, ' API PARCEL SLM LAND Use APp/l]1CATION N <br /> OWNER NAME 1 VgtfPHONE Jy►��' -I- U-S7�'� � <br /> OWNER ADDRESS O01y CITYISTATNIJp I i91 E 1 TCACAq <br /> qy$COCONTRACTOR INK DMIMOINC. PHONE_7A-I-ci2Z-112-0— <br /> CONTRACTOR <br /> NTRACTOR ADDRESS JIMC1TY/STATE0p M o q s3si <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CmISTATEJZIP <br /> LICENSE C-67 0 C-61 0 D-W 0 Ofher NUMBER ExpiRATIoNDATE <br /> DOMESTIC WELL SAMPLINO:XGeneral MineraXoRforrn Bacteria(4381) - Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Wfi(ti Private 0 In19411on/AgrICUllural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampting/Chancterizatbn /1 <br /> Pubtic Water System C`ry,7 <br /> a 911rw tan o`,ar eWaw Svwme m Naconr.a Nama a Pharr Number 1.� <br /> TYPE OF WORK New Well 0 Replacement Well 0 Well ARerstiOnModi9cation 0 Other /Vl, D <br /> Monitoring Walks) 0 Of WOWS 0 Son Boring(s) 8 0"O"lga 0 Gootschnlcal 0 of borinp O <br /> 0 Out-Of-Service Won 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair 12920 <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> W <br /> Drilling Method <br /> Mud Rota 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Otter_ (-/ ANT CpUN <br /> Proposed Wa11 _R ExuveDon In diameter 0 Open Bottom ❑Gravel Pack/Gravel Size , In diameter �E ENTAL <br /> 0 Cond casing in diameter / Conductor Casing Depth R RTMEDT <br /> Wall Casing Diameter. In. ThIckna./Gauge/ASTM Schad�_ 0 Steel Plastk D Stainless Steel ❑Other <br /> Grout Seal Depth R 0 Neat Cement(94 ID bagTS10 gel water) Send Cement sack morl7 gal water <br /> XBentonRe(20%soils) 0 Other <br /> Grout Placamard Method need 0 Free Fail 0 Over 0 Retardant/Accelerator(name) <br /> PeoeaTAl Inatallad By 0 Driller 0 Pump Conbactor ❑ Other <br /> 0 <br /> Concrete Pedestal❑Dimensions:Width_R Length R Thick n ❑Christy Box 0 Stove Plps <br /> P wp D Submenlblo O Turbine 0 Other HP Pump Set R SbsrKfi g Water Level R <br /> 1 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. 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 /> MINI M 48 HOUR VANCE NOTICE REQUIRED FOR INS <br /> C/ ONS-Pe SE CALL(209)953-7697 <br /> STONED TITLE J/r 11/tJ 1 1� DW�IT DATE <br /> N <br /> C1. <br /> 0 <br /> v <br /> DEPARTMENT U E OONLY <br /> Application Accepted By Date0/�0 o'LU <br /> Grout Inspection By 0 Area 7 Employee IDM <br /> Pump Inspection By Date Date LI SPECIAL Well Permit soil Boring Inspection By 0 WAIVER Received <br /> COMMENTS Date Constructed Well Depth h <br /> PE SC Ro"Ived ChocM! Amount <br /> Codes Info ash RomItEW Data parmw <br /> I DIn Lasts Invoices Well IDM <br /> 341 0 <br /> EHD 4346 SM111e ( / <br /> WELL PUMP PERMiT <br />