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100 Scary yl i3��� W <br /> ` WELLIPUMP PERMIT ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2FLTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDA13LE PERMIT �n CALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> 11 YEAR <br /> FROM DATE ISSUED <br /> Joe ADDRESS �/"� ( e Y c,,O (",1G/ C/I '7z5-?10 <br /> C:ROss STREET �� /'Ahn All , PARCEL S= LAND LW AIP IU 4 m <br /> 'OWNER NAME C Pnow r m <br /> (OWNER AoORE55 Vlp f� A N C C-) P <br /> CONTRACTOR Vc • j-C I l��1 J d ��� PHONEo <br /> DD <br /> CONTRACTOR Al (JL I C <br /> REQ►,S A <br /> 'SUBCONTRACTOR ' 1 <br /> PHONE N h <br /> SUBCONTRACTOR ADDRESS , Cr Y/STATErLP <br /> J LICENSE C-57 k G 61 0-09 Other NUM I-XPatATlON DATE 1 <br /> -� <br /> GEOGRAPHICAL INF RMATION: Coordinates X Y Township_ RangB section_ <br /> INTENDED USE Domestic/Private Irrigation/Agdcuttural Industrial Water Quality Monloting Sod Sampling/Characterization <br /> I Public Water System <br /> tt dMterorrc from Owns- &IMor <br /> TYPE OF WORK ew Well Replacement Well Well Afteration/Modification Other <br /> Monitoring Well(s)— #of wells Soil Borin9(s)_. A0boGeoteeMical__�°"r <br /> ` 4rt-OfSnrvice Wag OL2- Service i Renewal Cecestimneclfon Repair <br /> �/`ew Pum <br /> Purnp R eat Pump Repair Raise Wall Casing <br /> weu CONsTauCT1ON <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Wed Casing Diameter_in Thidaie Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(941b baV5-10 go/water) Sand Cement sack mcd7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fell Other Retardant/Aoceleratar(name) <br /> IPEDEsrAL Installed By Drilla, Pump Contractor Other <br /> Concrete Pedestal Dimenslona:Wath_ft length ft Thick in Christy Bea Stave Pipe r� <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOPE 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIONLAW W <br /> I 241110 NCE NOTICE REQUIRED FOR SPECTIONS-PLEASfE/7r/BALL(209)953-7697, <br /> SIGNED T fYj • / DATE_ <br /> LJ I <br /> pAY�EN <br /> RE�EIV <br /> 1 CO <br /> App �3 <br /> SSE IROUNM j1h� P/ TME!i SE ONLY <br /> ICIµpEP'� dicatlon Accepted ! Area'` Employee ID# <br /> Grout Inspection ey Date -�,---/i-1}�(, SPECIAL Well Permit <br /> mp ] <br /> PuInspection By Dat@ n WAiveR Received <br /> Soil Boring Inspection By Date <br /> Constructed Wel!Depth R <br /> COMMENTS <br /> PE SC Received C Amount Permitt <br /> Codes Info B Remitted Date Service RwpAW 0 Invoice a Well IDS <br /> 2 3 i-7, SK0 b-77210 woo Ny <br /> -13012 W&L(PUMP PERMIT <br />