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` WELUPUMP PERMIT <br /> ` SAN JOAQUIN COUNTY ENwRON .,,HEALTN DEPARTMENT 1868 EAIT HAZELTON AVBarE-STOCKTON CA 95205-(209)468-3420 <br /> l� NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED m <br /> IJoeAooREss /! r / <br /> 'Cross <br /> T.E., n�J APN Lc (V - �J�PA A. 3 I. TgN0 <br /> OWNER NAVE �� �C J U / t/l PNONlt�( fj <br /> - a <br /> OWNER ADORE• - CRI' A ��( ` fit'+ Ll L7 <br /> CONTRACTOR C P • <br /> CONTRACTOR ADDRES (/ � VV G CXAW <br /> (C! <br /> U <br /> SUBCONTRACTOR �� <br /> SUBCONTRACTOR ADOReSS IV/ 1 CR_YISTA7T�E(ZP/ <br /> LICENSE C-57 ✓ C-61 D-09 Other 1. `+-'✓� OATL <br /> Geor.RAPwCAL INFO Coordinates X Y Township_ R2nge Section <br /> INTENDED USE omestictPrivate IrrigationiAgricuMral Industrial Water Quality Mordwing Sell Sampin9/Chracterizatim Public Water System <br /> ff different tom Owner or Prom N.,*er <br /> TYRE OF WORK . New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) s Of wells Soil Boring(s) of bol Geotechnical eOr 1� <br /> Out-OfSerwce Well Out-Of-Service Wel newal C ossCmnection Repair <br /> New Pu'p Pimp R cornent Pump Reps, Raise Weil Casing <br /> WeLL CONETRucnoN <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Peck/Gravel Sae in hSenheter <br /> Conductor Casing it diameter / Conductor Casing Depth ft <br /> Well Cuing Diameter_in ThidmeWC-aufldASTM Schad Steel Plastic Stainless Steel OTw <br /> Grout Seal Depth ft Neat Cement(94/b bagVSTO gal water) Sand Cement sack mod7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fail Other Retardant/Accelerator(name) r'1 <br /> PERE,TAL metalled By Driller Pump Contractor Other <br /> Concrete Pedestal Dimenalpu:Width ft Length R Thick in Christy Box Steve Pipe <br /> PUYR Submersible Turbine Other HP Pump Set ft Standing Water Level _ ft <br /> l HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN 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 LAW <br /> MINIMU 24 U ANCE NOTICE REQUIRED FORANSPECTION/S-P E CALL(209)953 7 97 w <br /> SIGNED Tm-1 �� / DATE D L% `"i <br /> � I <br /> I <br /> Z Wv �d <br /> LCLJ 7 00 z 12 Iz A <br /> c <br /> C:2oo <br /> }U a t'' <br /> iw o � � D <br /> 2 Z Zwui <br /> + 1 0� <br /> �` OUNW <br /> TTMAE ENT <br /> I <br /> RF PA TMS SY / <br /> c f <br /> Applik:etion Accepted B 1. ib �I �^' Area playas IDh7 �! <br /> �� �V(yN/LL/, <br /> Grout IrsDedlon By Date CI <br /> j'I) SPEAL Well Permit <br /> Pump Irspec.on By Date t'(I�LA 1�� WANER Received <br /> Sal Boring Inspec on By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC <br /> ' Received Cj h3ecad/�p Amount <br /> v tII DPermit/ <br /> Invoice i Well IDS <br /> nff. Cash SeAceRemeatsCodeB / v <br /> I <br /> Tr— <br /> END 4:m WEIL PUMP Pawn <br /> VW t2 <br />