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Tri�w,,� Strt� 1-��—IZ D51� <br />WELUPUMP PERMIT <br />SAN JowoulN COUNTY ENVIRomwmTAL HEALTTI DEPARTMENT 1868 EAST NAZELTON AVENIN - STOCKTON CA 95205 - (209) 46&3420 <br />NON-REFUNDABLE PPERmfr I CALL 2/09) 951-1697 FOR INsPEGTION$ EXPIRES 11 YEAR FROM DATE ISSUED <br />Jos ADOREss <br />14 ` ' (1' 0 I 1��t / ! I r t-1 CrrrmP co C'c / <br />CROSS STREET <br />APN Z� <br />% <br />U Q ( <br />OWNER NAME <br />\ <br />CfTj <br />OWNER ADDRESS <br />1 <br />/ <br />CONTRACTOR <br />^ 0 61 <br />/v., 1` <br />u <br />CONTRACTOR ADDRESS <br />1 <br />L <br />SUBCONTRACTOR <br />PARDEL SMf ' I LAID <br />FA <br />g <br />z <br />m <br />-Z, <br />rUBCONTRACTOR ADORES$ Cm/$TATf1i,L+V. (� IV (J"I <br />CENSE C-57 y�/l C-61 D-09 0111, N. 4' W l: r,.TTON D.12 X r <br />GEOGRAPHICALI TION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE omeStic/Private InigationlAgncultural Industrial Water Quality Moniving S00 SamplinglCharacterization (Z <br />Public Water System <br />K defertvrt hOrri owner Wzar SyStitni Narne y <br />TYPE OF WORK New Well Replacement Well wen Alteratinn.T!cdification <br />Monitoring Well(s) 15 of wells Soil Boring(s) A otbond Geotac nical aOrbO""0` <br />Out-OlService NI O — Out -Of -Service We11 Renewal Cross -Connection Repair <br />Oril6ng Method Mid Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well DepO ft Excavation in diameter Open Bcttan Gravel PaddGravel Size in diamete <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Wed Casing Diameter _ in Thxkness/Gatlge/ASTM Schell Steel Plastic Stsmlms Steel Othar <br />Grout Seal Depth ft Neat Cement (94 !b bagIS-10 gel water) Sand Cement sack rnixr7 gal wate <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fag _Other Retardant / Apoeleratpr (name) <br />PEDESTAL Installed By Driller . Pump Contractor Other ---- <br />Concrete Pedestal Dimsnslons: Width ft Length R Thick r in <br />Christy Box Stove Pipe <br />_ auomemole i uroine Llmer HP / ' I I Pump Set L ( ft $[adding Water Level ' i ft <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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOURA� CE NOTICE REQUIRED FO•p\yRNSPE,C/TlIO�N�JS --PL/EAS53 <br />/E CALL (209) 9-7697 <br />/� <br />SIGNED G,)�it/Y TITLE LC. S L(yrr�l,� ! J DATE I <br />Application Accepted B9 <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />41 <br />s <br />w <br />S <br />i,qL HEfii.71- <br />4 PARTMENT FSE PNLY I <br />Date Area Employee 11?k-� a <br />Date ell Permit jj RFS 71 <br />�— Date " I WAIVER Received F le <br />Date Constructed Wee Depth ft JAAf 2 d Q <br />zn2 WE.L,PJW PERMIT <br />�,QU -U%J <br />TH pONM co�h'Ty <br />