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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECnONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jas ADDRESS � NrIAN CnY/aP <br /> r o <br /> CROSS STREET / /\ I�.c✓ APiN�I/J''�/��' 1�L1' lL' PARCEL SIZE USE APPLICATION# J� m <br /> OWNERNAME m h 110 ! I'AJ/.t' I-� �J�AIS�s l _. ��F�c / /t O —StJ�� <br /> OWNERADOREss LAJ CRYISTATEMP &AVT�yP <br /> CONTRACTOR / PHOIYB�w" �l•�"� <br /> CONTRACTOR ADDRESS •-�� n. V CiTYISTATE/LP )LjLLA • 2— <br /> SUBCONTRACTOR. PNOM <br /> SU6CONIRACTODRESS CfTY/STATE/ZiP <br /> LICENS 0 CS7 n C-61 n D-W r.Other NUMBER`� l'4 EXPIRATION DATE�7 � <br /> GEoaaAPACALINPO H: Coordinates X Y Township_ Ranger Section_ <br /> INTENDED USE Omestic/Private C Irrigation/Agricultural D Industrial 0 Water QuaGly Monitoring 7 Soil Sampling/Characterization <br /> U Public Water System <br /> If different hom Owner. Water SWem Name m orphonaNumoor <br /> TYPE OF WORK Aew Well 7 Replacement Weil C Wil AlterationModiffcation G Other_ Iq <br /> n Monitoring Well(s) #of webs r Soil Boring(s) 9 of bmnp n Geotechnical ser <br /> I Out•Of--SeMce Well C Out-Of-Service Well Renewal Cf Cross-Connection Repair <br /> U New Pump C Pump Replacement C Pump Repair 0 Raise Well Casingb/ <br /> WELL CONSTRUCTION ' <br /> Drilling Method 0 Mud Rotary G Air Rotary C Auger Cable Tool G Push Point r Other <br /> Proposed Well Depth &I ExravaDon —[.diameter ,/Open Bottom 7 Gravel Pack/Gravel Size <br /> — <br /> D CondrIcWr Casing In diameter I Conduct Gdsing Dep R N IE7/v � Ull�l LO <br /> Well Casing Diameter m Thic[messfGaugeIASTM Sehed reel I IJP antic n Stainless Steel n Other N>�9FN1,UN� <br /> Grout Seal Depth)V R 0 Neat Cement(94 lb bag/5-10 gal water 6 Sand Cement„ sack mixR gal vita AgRT AC <br /> 0 Bentonite(20%solids) G Other MFN� <br /> Grout Placement Method El Pumped 7 Free Fall G Other =Retardant IAccelerator(name) <br /> PEDESTAL Installed By nller in Pump Contractor n Other <br /> rI CO erste Pedestal rIDlmansions:Width R Length R Thick in '1 Christy Box -i Stove Pipe <br /> a_ <br /> PUMP Submera[bleu Turbine 0 Other _ HP_ ,_z_ Pump Sat R Standing Water Level R <br /> 1 HEREBY CERTIFY THAT f 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 COMPENSARCIIIT'L/LWS. <br /> MINI ! UR ADVANCE NOTICE REQUIRED FO_ SPECTIONS-PLEASE CALL(209}953- 697 <br /> SIG ' \ TITLEf-�.•3-+1�'\ _ — DATE / 9� <br /> i <br /> I Fly <br /> 1 <br /> P�► MENftAlve <br /> Appr�ation Accepted By Data Employee ID#-�Grout Inspection By DPECIAL Well Pefmlt <br /> Pump Inspection By to ❑ WAIVER Received ;� <br /> Sail Boring Inspection By Date Con cted Well D4pth q ft <br /> COMMENTS a 7 - 77— <br /> PE Sc Recelved Cheeka! Amount Date Parmid InvoltaAl WeIIID# <br /> Codes Info By Cash RIM10etl Solyke <br /> vi LAc� <br /> WELL HUMP P.-Il <br /> EMD 43-W <br /> .112 <br />