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b+ <br /> I�3o WELL/PUMP PERMIT <br /> _ SAN JOAQUIN COUNTY ENVIRONMENTAL HE-T9 DEPARTMENT GOO EAST MAIN STREET-STOCKTON CA 95202-'(209)458-3429 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /^� p(T ,,II <br /> JO$ADORD <br /> ESS � 'M I"L4 4r'F1.:)4 CITYILIP L0.T,t^J,��� <br /> CROSS STREET. S. Lo "-. R API C-l 1?6—120-1* 3 PARCEL SIZE 2=7' LANE)USE APPLICATION�f <br /> I OWNER4MMFs v� /f oOYT 1 hvoi9 r�I ,,,t7. WOI. -r••,,,coo"CS PHONE y <br /> OWNER ADDRESS 0r01 NW .rd 5><, CITYISTATEIZIPr j r{g C'j.�y ok-- 7,3lp <br /> CON'FRAGTOR NG .b ?,,,C. rp2rok ..- PHONE-U07� 5--o' <br /> !� <br /> CONTRACTOR ADDRESS N. 1N{1424 cITYIsTATEIziP <br /> SUBCONTRACTOR 'V ;PHpNE�-? <br /> SUBCONTRACTOR ADDRESS P-0 '976 CiTWSTATEIZIP - d. I W ' <br /> LICENSE .0-57 C 6-51 i.f D-09 d Other NUMBER_-716d0' <br /> ;( .EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Townelif <br /> p_ Renge Section <br /> lNTENDEDU6E: Domestic/Private C lmigation'lAgricullural ❑Industrial D Water Quality Monitoring xSoilSampling/Characterizalion <br /> I!PUbiIC Wafer System <br /> If different from'Owner, a er y em NErIff �njarA Name or'Flinne MjMner ' <br /> i <br /> TYPE OF WORM 0 New Well DReplacement WoU C]Well AiteratipnlModirioation a Other <br /> n Monitoring-Wells) #'afwells r Sail Borfn s 0 Q borings of Wrings <br /> gOGeotechnica! <br /> D Out-Or-Service Well Oul-Of-Service Well`Renewal 1)Cross-Connection Repair <br /> U Nw-- ❑Pum Re lacernent u Pump Repair L7 Raise Well Casingy _ <br /> WELL CONSTRUCTION 4l� <br /> Drilling Method C Mud Rotary D Air Rotary Auger L Cable.Too! j Push Point _ Other <br /> Proposed Well Depth��III Excavation in diameter C Dpen Bottom Gravel PacklGravel Size in diameter <br /> i�ConduelnrCesing indiameter I Conductor Casing Depth it <br /> Wail Casing Diameter„In ThlcknessIGaugelASTM Schad a Sleet Ci.Plastic LI Stakniess Steel ''l?Other t/ <br /> Grout Seal Depth I <br /> P ft `�.Neal Cement(9416 bag15-T0 ga1 water) C Sand Cement sack mirA gal water i <br /> �Benlonite(20%solids) D Dthar <br /> Grout Placement Method D Pumped C Free Fell gother U Retardant l,ACceleraior(name) <br /> EDESTAL Installed-By C Drille"r U PumpContraclor U Diher <br /> Concrete Pedasta)Dimerislcns Width N, Lgnglh R Thick in U Christy Box C.Stove Pipe <br /> PUMP LI SubmersibleG.Turliine El Dther HP Pump SO!.—ft Standing 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 i <br /> W <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE'WITH ALL i <br /> WORKERS COMPEt+ISATlON-LAWS. <br /> IIUIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS' <br /> Staffed TITLE Sr. �a DATE 1 O F <br /> No <br /> i---------------- <br /> I <br /> NJ A COL T <br /> TIUZF�Afflm ;N IF OL <br /> IR <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date. !(Q / � /'y <br /> Area Employee 1D11 `�.( <br /> Grout lnspegion By pate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring.Insp.6cl In B ate Constructe <br /> COMMENT d Well D pth g <br /> Pe CReceived C 1 Amount RermtV <br /> Codes Info 6 a Remitted Date Service Re nest# Invoice# Wei 1D# <br /> u, Q Ub3 <br /> , <br /> EH➢43-M <br /> afa9lde WELLIPUMP PERMIT <br />