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1 0 'IN WdH':Z 9l0Z ti q I j ILII J pIAIIDay <br /> WEL.LIPUMP PERMIT <br /> SAN JOAGLMCOUN1YE FioNmENTALHEALTHDFm:RTM£ 9BWEAGTHAMTONAVENUE-STCCKTONCA95205-(2W)498-3420 <br /> NON-RE,rUNDABLE PES CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROhf DATE ISSUED <br /> J[�ADDRBs 39 r; rh,-r�y1 and Avg c m;Stockton 9521 5 a <br /> Rd p Q <br /> C7ADs857RE6T waterloo AIN J 9 C')� PM4Z5�('�%�J LAND USE APAlItAllOf,IC y <br /> Grace Azevedo <br /> ovaNEat NAN,,E _._... Pxattaz 0 9-8 8 7-1 988 <br /> �^ <br /> ov,KeRAODREss P-O- Box 1530 cflY1STA-mzjp L i ntj en C A 95236 <br /> Cd NTRAC'MR Purviance Orillers,rnc I,,,Or09_ 877-3554 <br /> CCl=RAc:MR ADORF9133 D• 0. o x 64 CrivisTATErap L i n a en, CA 9 5 2 3 6 <br /> SUSCONTRAGTDR PHONE <br /> SUSCONTRACMR ADDRESS CITYISTATErap <br /> LNOENsE L C-61 =D-W OUw NUMBER 377923 Evip rm DATE 7/31 /1`I <br /> GEOGRAPMICALINFORM71ON: Coordinates V Towashlp_ Range SeWon <br /> 104TENOED USE FI DomaUidPrivale, C InigatfordAgricv[ural 0 Industrial Li Water Qu2l0y Manit0nnq Soil SanplinglChararteriation <br /> Pudic Water System <br /> YdRfcredfrom C.+ner. er ys amo o a aM� � r <br /> TYpEOF WaRK a NeW Weil _Paplacementwell !°°Welt Altenafion/Modification ;7 Other <br /> Monilowv Well(s) *al weirs r Soi Baring(s) 7.,bmMea i Geolectnlcal a of bori os <br /> r•Oul-0f-endo Well 7 OUZ-OFService Wefl Renewal : Cross Conne=on Repatr <br /> C New PUMP Z P=p Replacement 2#Purnp Repair U Raise Well Casing <br /> IWEU CONa7RUCTIQN .2 r <br /> Drilling Method _Mud Rotary L AfrRotary _Auger _CahleTocl _Puah Point _ Other <br /> Proposed Wall Depth ft Excavafion in diameter --Open Bottcm -rGravel PackJGravel Size in uiamete <br /> Conductor CasingIndiameler ! CdnuucorCasiNDepm ft <br /> Well Casing Ofameicr_In 'hldvtesJGauge1ASTM Sched Z Steal C Plwbc C Stainless Steel C Other <br /> Graut Seal Depth t2 C Neat Cement 1941b bag/SIO gat K,2W 0 Sand Cement sack rnhd 7 gat vrater <br /> ,lBontotute(2D%solids) (;Other <br /> Grout Placement I`dethod n Pumped C Free Fall _ Other L'Retardant/Acceferater(name) <br /> PeaESTai Installed By 0 DH3er C Pump Contractor - Other <br /> i!Ccacrele Pedestal!_Dn <br /> imesionstVftth ,R Length ftThlcx In L'Cnrfsty Bow L Stove Pipe <br /> Puha Id Submer,ib[e_;Turbine !�Other HP Pump Sei ft StanCinO Water Levet tl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE CONE IN ACCORDANCE%VrM SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AC TVE WITH THE CAUFORNjlA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALI. <br /> WORKERS COMPENSATION LAWS. <br /> IN! 24 HD NCE NICE OTREQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 Pq *10VT <br /> sl Tm_E Corporate Secreta&& -7 RE�ENED <br /> " <br /> 09JOAQU <br /> ?016 <br /> f f as MY <br /> I Farr <br /> l <br /> t I <br /> I I LAIVE D <br /> 4 2016 <br /> T- TAL HEALTH <br /> R MACES <br /> JtI <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L _ nate `_- "1 V Area, Employes 1Ott y_ <br /> Grout Insp9Wo i�Y 7 'e Data SPECIAL Well Permit <br /> Pumpinsp t� Dad. :1 WAIVER Received <br /> Soil Bering Insperiton By (late Constructed Wea Depth ft <br /> COMMENTS <br /> PE SC Received CherioR AmountRate Partmtl Invoice# We1tID# <br /> Codes Info B h Remitted Service Re vest# <br /> 19003 33 <br /> EPIC 9 <br /> "30r12 A 752,TLI 'NBIr�UF:P Pt7tf.;tT <br /> V-d d917:0 L 60£0 deS <br />