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WELL/PUMP PERMIT <br /> SAN JOAOf1IN COUNTY ENVQtONl1ENTAL HEALTH DEPARTMENT 1868 EAST HAZPLTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIITI /� yy.CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDnrse V L1.o 1 ,, <br /> CIn2P_T1 'ax\ k_foil <br /> - OV ARCEL SIZE AAND USE APPLICATION#CROSS STREET ApN <br /> OrilER NAME PA- <br /> PHONE <br /> 01VNER ADDRESS nO eoxL�- <br /> CITYISTATERIP_�✓^��� ��s <br /> CONTRACTORCe.7AI � t„L• <br /> — GPHONE y� <br /> CONTRACTOR ADDRESS��VTM��L' O r CITYISTATE/ZJP �/ • A� �U <br /> SUBCONTRACTOR PHONE <br /> SUB RACTOR ADDRESS Cfn/STATEJZIP__ <br /> C _ l C-61 D-09 Oliler NUMBER EXPIRATION DATE_ <br /> GE CoordinatesX Y Township_ Range_ Section <br /> t ImgatlDnfAgrCUltural L Industrial _Water Quality hlpnitoring L SO4 Sampling/Chareclerizallon <br /> t- If alA'aromTiom Osm�ior� --'CJ7�j�Ycn punw "� <br /> a ameor na um a <br /> TYpE OF WORK _New Well L Replacement Welt L Well AllerationAlodfication i Other <br /> _ Mmitoling vfeB(zl.._...._..__.,,,.,,.,�� e,.l!,,,;.,,.. ---- <br /> .r.,. !.. ...; w51�; J GeOtecirNcal :arwnniro <br /> -Out-0fService Well f ^-OfServico Well Renewal -1 Goss-Conrection Repair <br /> -New Pum f Pum R lacement Pump Repair -1 Raise Well Cash <br /> WELL CWeLL C—�CTI <br /> Drilling Method _Mud Rotary L AT Rotary L Auger -Cable Tod L Push Point L Other <br /> Proposed Well Dcpth fl Ecavatlen in diameter L Open Bottom _Gravel PalkdGravel Size in dameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter In Thickness!GaugelASTM Sched___ Steil tic Stainless Steei I Other <br /> Grout Seal Depth it I Neal Cement(9416 bay5.10gal water) I Sand Cement sack mixt/gal Water <br /> - <br /> Bentoolte(20%solids) 'I Other <br /> Grout Placement Method L Pumped L Free Fall L Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By l Duller J Pump Conlrad0r i Other <br /> Concrete Pedestal IDimen&ions:Width_It Length it Thickin I Christy Box I Stovepipe <br /> PUHP C7 Submerse e Turbine -1 Other HP Pump Set A Slanting 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALJFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 24 iOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED t TITLE �L j.-=� i� <br /> DATEREC <br /> ' <br /> MAY 0 <br /> 01 <br /> ENVIRONME FN�igo���Co <br /> PERMIT/ �ryDFpq&N��), <br /> ------------------ <br /> P RTMENT U E N <br /> Application Accepted By pate D Area Employee IDi,, <br /> Grout Inspection By Date_ 0 SPECIAL Well Permit <br /> Pump Inspection By t Date '1. fl WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth 11 <br /> COMMENTS <br /> PE SC Received Check#I Amount Permitf <br /> Ca Info B Cash Remilted Date Service Request# Invoice# Well 114 <br /> F D 43cC tTlk�� <br /> 4W12 7733 <br /> ��6/ 1ti'E!.:IFVI.1?CERI,IIT <br />