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WELUPUMP PERMIT <br />SAN JOAfauim CouNTY ErtnrmmffHrAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209) 4683420 <br />N-KEFUNDABLEFPER%MIIT <br />';ALL f/ZU�9�) 953-1597 FOR INSPECTIONS <br />1 T LAX f-KOMLJJATE ISSUEL <br />ADDRS `Y J �`-�� �- L(/l7bY <br />ES <br />J <br />L. DTII crTY21P <br />//r.Artrcr� <br />Ac,+,m. <br />` ILZ/06 <br />SS STREET �il& 64t <br />APN I 'T I G�PAROEL S� <br />LAHo USE APvuCATxm # <br />IER NAME L He /v <br />(.A <br />PHONE <br />LERADDRESS <br />CrrYlSTATEiLfP � <br />J <br />/ <br />�;%7/!�f5 2 <br />TRACTOR <br />soA)s rjx <br />PHONE a09� <br />nlA% <br />� <br />TRACTOR ADDRESS /006.2 /t1ECa.J <br />/`TOPE ,eD CMYISTAwz p <br />C -,A r- C-4? <br />49 <br />ADDRESS nCRT/STA7ElLp <br />57 1 L C-61 L L D-09 I L Other NtgmER 7 Uy ExPrRAnoN DATE $- 31- ) <br />GEOGRAPHICAL IKFORMATION: Coordirutes X Y Township Range 9eetlau <br />INTENDED USE bC.Domestic/Private L lrrigabon/Ag7updtural I 1 Industrial I Wafer Quafity Monitoring 1 i Soil SamplinglChareder azlim <br />L L Public Water System <br />e dllfererd from Owner: Water Systern Nam Contact Nam or Phave Nuaftr <br />TYPE OF WORK I I New Well i L Repiacement Well I I Well Atteration/ModificahOn t I Other <br />1 I Monitoring Well(s) S of wells I I Soil Boring(s) C o1 Fags I I Geotechnical 0 of borings <br />I L Out-OfServtce Well I I Out X -Service Well Renewal I I Cross -Connection Repair <br />Drilling Method 1 L Mud Rotary I L Air Rotary L L Auger 11 Cable Tool 1 1 Push Point 1 L Other <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom 1 1 Gravel Pack/Gravel Size in diameter <br />L 1 Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Tludmess/Gauge/ASTM Sched I I Steel I L Plastic I I Stainless Steel i I Other <br />Grout Seal Depth it I I Neat Cement (94 lb bag/5-10 gal water) L I Sand Cement sack mixr7 gal wafer <br />I I Bentonite (20% solids) I I Other <br />Grout Placement Method I I Pumped L I Free Fall I 1 Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller I I Pump Contractor I I Other <br />I I Concrete Pedestal Dimensions: Width ft Length ft Thick in I I Christy Boz I L Stove Pipe <br />IL.—U— Ksubmersblel I Turbine I I Other HP C_ Pump Set_21,,_'Y it Standing Water Level <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 />MVjNILMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ��vv <br />SIGNM B� TRLE DATE Z�- , <br />CEIVEp <br />P a s ao1a <br />HNrH <br />■■■■■■■■■■■■■■ �■■ ■■■■■■■n.■.wt�..l�.�l■■■IIS■..'7■■■■ <br />04 <br />• <br />Date A. q Employ. 011 nc <br />Grout Inspection By 0=ws Date SPECIAL Well Permit <br />1 <br />Purnp Inspection By <br />Soil Baring Inspection By Consbucted Well Dep -di ft <br />fel WARIER Rereived <br />COMMENTS JIJO LL61) C;42 - <br />DID 43-08 WELL I'Muff <br />a„aa <br />