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ZY,}k�awl su,,, 12-1011, 0*� <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY EWMNMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96205.(209148N420 <br /> NON-REFUNDABLE PERMIT CALL 209)963.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED x <br /> Jog ADDRESS <br /> I1 3965 ru P" II Avg CITYILP �<[ l0 �'S3 Z.t s <br /> CROESSTREET f9,Aie%C <br /> icI1 1C APH 2215100q PARCEL Sons .T LAND USE APPLICATION# <br /> DINNER NAME 32rh PV" `rivocr4,[$�IId VL UavT :CYIYR I 6 3 <br /> '. _ \ SI S CY ,STATEZP ut ki �lS 'S <br /> OWNER ADDRESS TJX(—('L1 <br /> ` T PHONE �C1-96 f <br /> CONTRACTOR 64Ly-g 1,,..� P/ � ' I /5L� <br /> CONTRACTOR MORRIS l C f�q I,!�n ✓� OWISTATEMP /T"IyH ✓ tC XL %` ��Y <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADM" CITYISTATEMP <br /> LICENSE C-57 LG61 JD-09 JOMa ea��/(����y{ �I NuM9Ealo09L•OY EXPIR <br /> iA <br /> (TION DAIS p/2�31 <br /> GEOOMPHICALINFORMATION: COOrdlaabsX9�1.�L l'If 1 Y —12,0816S'71 Townships Ren9e I IG SaCUOn <br /> INTENDED USE .:=,as P.,,ate 1mga0uNAgncUNUml _Imusens � van,Quality MONtanng _ Soil SamPlthglCharedefaaeon <br /> iPUM"I.mYetl�erS em Ser m arm <br /> TYPE OF WORK ew Wen Replacement Well Well AlfemBonMlotlMcetion Sol mer ♦oIDMilpe <br /> MoadOdnpice W_ <br /> i Of wells Son BoruQ(S) Geotechnical <br /> _Out-Of-Service Well JOut-Of-Service Well Renewal _ClossAonnection Repair <br /> _New Pum j Pum Re acement J Pum Re air J Raise Well Cast <br /> WE LCONSTRUCTON <br /> Drilling Method Mud Rotary J Air ROtery _.Augef J Cable Tod Push Point J Other <br /> Proposed Well Depth 3,0e) It EscaYe6on ;t 3L In diameter J Open Bottom 'AGmuel PGCVGre-1 Size rRMr5ltemalar <br /> CondUdor Casing in diameter I CUIMuctpr Caseg DePOI ft <br /> Wall Casing Diameter fl,In ThlcknesSrGeuge/ASTM Schad Cnll!2 ii I Steel )&last. ;Sbinlees Steel J Other <br /> Grout Seal Depth IVC R j NOW Cement(94 fb 689/5-10 gal water) Sand Cement sack mbUr gel water <br /> NSenorita(20%edlde) _OBIef <br /> Grout Placement tllod' Pumped JFree Fal .I Other RebrOant l AccNarabr(neme) <br /> E12LUAL Installed By J Diller J Pump Contractor _ Other <br /> _Concrsb Psdasbl.',Dimension WRlth_R Length ftThidt_In -Ghdary Box JStovs Pips <br /> Pump J Submersible:Turbine -Other HP_ Pump Set R Standn9 Water Laval R <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 BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963-7697) <br /> SIGNED TITLE L !' n _ DATE L LZ( I <br /> A4 yM <br /> )Y C;� vT <br /> QOM <br /> h��N7y <br /> QT <br /> pATM <br /> kENT USE rN_LY <br /> Ppplkation Ampted 8y�L1R{Ll'PSA w C�'1FI/t Dele I� v Area_ Employee l OR <br /> Grout Inspection By Dale ❑ SPECIAL WeII Permit <br /> Pump Impaction By Dale ❑ 111 Recoivad <br /> Sol Boring Inspection BY Dew Constructed Wall Depth ft <br /> COMMENTS <br /> PE BC rteeslvsd hackN on <br /> ParmRlU InveinM Wa111De <br /> Codas Info B Cash Remitted Dela Serviceuesti <br /> yrs, MPPBRMD <br /> exp„m Walt, 833a�s <br /> ,NN„ <br />