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111- I e!i <br />PAYMV <br />RECEIV <br />I <br />iniha( scan y1(alp ftt4 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVISOM - STOCKTON CA 95205 - (209) 4683120 <br />NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIOMS EXPIRES 1 YEAR FROM DATE ISSUED <br />,' Joe ADoftEss IU 0 ff P- Vey Kd <br />11 <br />CROSS STREET V u V ,/ /�� v--0� �A�R�C.&LQSQB � ®LAND UsE UCATIO_N# ---777 <br />IOwRER NAME i U �/ -!/t 1�1XDG� r'21�r <br />(OWNER ADDRESS Ut ✓P r, C( A <br />i� /A(/� CONTRACTOR /r''/ /C�� �/r fn S / I GPHo[!OC �/ "� U <br />(/�/ <br />CON -n ACTOR ADD ✓�, V ✓ RYiSTATEii� � <br />61 <br />(/ l) <br />r Tg— <br />'SUBCONTRACTOR <br />fv <br />SUBCONTRACTOR ADDRESS I CCRY/STATEpfrZP I `• '!]"!'/" <br />IUCENSE C-57 CSt D-09 Other NUMeHi Or'�lY Y lY A1E <br />GEOORAP+tcu9t4MAnoN: CoordinaEes X Y Township _ Range Section <br />i yr errucu uae y Domesucfrnvate mganorvagrta:aural Industrial Water Quality Morrmring Soo Sampling/Characterization <br />Public Water System_,__._, <br />It n amermt trom Uwnx — WdFi3 <br />TYPE OF WORK New Well Replaow"M Well Well Akerabon/ModificationOther_ <br />Monitonng Well(s) A of wells Sod Soring(s) a0f 0Of gl Geotechnica tldtw gs <br />Out-OfService Wet Out-OfService Weil Renewal Crow: -Connection Repair <br />New P"Jew m�P 'mpR�mp R�eM Pump Repair Race Wail Cavno <br />Drilling Method Mud RDt2ry Air Rotary Auger Cable Tool Push Pam Outer <br />Proposed Well Depth ft Excavation in diameter Open BWfnm Gravel Pack/Gravel Sae In tllaneW <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Weer Casing Diameter __ in Thidotess/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cern®M (941b bag15-10 gal water) Sand Cement sack mixr7 gal water <br />Bentonite (20% Solids) Other <br />Grout Placement Method Pumped Free Fail Other Retardant / Accelerator (name)_ <br />PEDEVAL Installed By Dnller Pump COntracfnr Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Brix Stave Pipe <br />PUMP `' Submersible Turbine Other HP _ Pump Sot ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WfTH 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 WfTH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM20CHOUR ADVAN OTICF RFnLIiRFn FnR wcaccnnuc _tat morn rAt t rens, <br />'t� <br />1 v <br />Elfin <br />rAL �.& <br />ApR <br />18tq�% I I I I - <br />h' <br />�11RONMEN y,Eµi <br />H'F�� DEPAAT <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Sal Boring Inspequ.- By. <br />N <br />COMMENTS ✓ <br />RTMENT SE ONLY <br />Dace i <br />Date <br />_ Date <br />A.4 1�7d, Employee ID# UW <br />SPECIAL Well Permit <br />W %xva-R Rec£':ved <br />CofNItrYeOad Woo Depth tt <br />1/01 LQ In. In , l i n. r � . 1 n4 <br />Zrd 12 WELL HUMP PERMIT <br />