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i <br /> WELUPUMP PERMIT <br /> SAN JoAOuw Courm ENVIRONMENTAL HEALTH DEPARrre(r 1 ass EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7897 FOR INsPECnoNS EXPIRES 1 YEAR FROM DATE ISSUED <br /> CITYZP > <br /> JOB ADDRESS p <br /> CROSS STREET N — PARCEL SME 14_LAND USE APPLICATION M <br /> PHONE ' t ` 2, <br /> OWNER NAYS Y vrI <br /> OWNER AOORESS " ✓ CrTYISTATEMP <br /> PY n <br /> CONTRACTOR V I PHONE <br /> CONTRACTOR ADDRESS Cm/STATErzo <br /> I. <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS Cr"13TATEMP <br /> UCENSE C-57 0 C•61 0 D-W 0 Other NUMERUE222- ExPHUT10N DATE <br /> DOMESTIC WELL SAMPLING:*General MlneraUColiform Bacteria(4391), Dibromochloropropane(4392)o Arsenic(4393) <br /> INTENDED USE tlrJPrivate 0 IrtlgaborJAgricu Lural 0 Industrial 0 Water Quality Monitoring 0 SOB Sampling/CharaCterization <br /> ❑Public Water System A <br /> N do.—I kom Ol Walar sy.%n Name Cmtaat Nary W Ph y e Nurnbw .q/ <br /> TYPE OF WORK New Well 0 Replacement Well 0 Well Ahratlon/Modific bon 0 Other nn <br /> ❑ onitoring Well($) M of wells 0 Soil Boring(s) s°}hOfr'ae 0 Geotechnical a d kO`I"� ��4�-1 I I <br /> 0 Out-Of-Service Wap 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair � <br /> 0 New Pum 0 Replacement 0 Pum Repair 0 Raise Well Casing `(� �•J <br /> Drilling Drilling Method�M d R�q{ta ❑Air Rotary ❑Auger 0 Cabe Tool 0 Push Point ❑ Other �Y Q(/�/✓ 2010 <br /> Proposed Weil Da th N\T II Exgvatlon tl In dlamster 0 Open Bottom ❑Gravel Pack/Grwel Size in diameter �y 0N/y C� <br /> 0 Conductor Casing in diameter / Conduct Casing Depth It �FAq RNT�NTy <br /> Wall Casing D(ameter, in. T ckr*sa/GaugWASTM SChed7 0 Steel )(Plastic ❑Stainless Steel 0 Other T MFNT <br /> Grout Seal Depth 11w R 0 Nut Cement(94 fb bays/0 gal wafer) 0 Sand Cement sack mix/7 gal water <br /> (Bentonite(20%eoW3) 0 Other <br /> Grout Plaument ethod Pumped 0 Free Fail 0 Other ❑Retardant/Accelerator(name) <br /> PEOESTAL InstaIF By 0 Driller Pump Contractor ❑ Other <br /> 0 Concrete Pedestal ODIm Ions:Width it Length R Thick in 0 Christy Boz C Stove Plpa <br /> PustP ❑Sutxnerabso Turbine 0 Other HP Pump Set ft Standing Water Level n <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE 130ARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION!,-PL SE CALL(209)953-7697 <br /> SIGNED Trn e ' DATE <br /> i <br /> ZA� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Data Area �i <br /> Employee IDM <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Data ❑ WAIVER Received <br /> Soil Boring Inspection By Dole Conabucted Wall Depth ft <br /> COMMENTS i'1. !1, 1,o/rt St'Ei[t�/c" I wr <br /> t1tILI"'u) rltt 05�. qI'C ly`rrT (r. L, "Ota°Y' 'If^QS <br /> PE SC Raalved Cheap/! Amount Porrnlf/ <br /> Codas Info Invoice t Well IDM <br /> Cash Remitted Dae R til <br /> =q3 C1 L <br /> 3`ic+t r`' ., i• t � � <br /> END 41.ae aglfle —7/7 VrELL IPLIMP PERMIT <br />