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WELUPUMP PERMIT <br /> SAN JOACMN COONTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 96202 -(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> ('2__019953.7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> \ J08 ADDRESS �E Aw�1/0 • `Q ✓ yam• Cm�RJpv <br /> CROSS STREET O"VA APN ZD7 (-0U 04 PARCELSIZE/% LANAPPLICATION Use <br /> { <br /> 10 <br /> OWNER NAM! `Wr.1I (.i/a��mW� #SI uF C�. Tr �'g fw rl� J�O <br /> Omm ApuReas j�T£J� \\�h1L.FUiIL� 1tZ.a CmISTATE P Q 21, <br /> CONTRACTOR /_ r,d PHONE 2 <br /> Corato CTORMgKES9 1(�D Ir 11 in � Cm/STATEZP mra I,tAA L753/U <br /> SpatoNTRAcT.R I PHoN! <br /> SuecowncTOR AppnEeb Cml$TATERN <br /> LICENSE C-67 f"I II D-09 IIOdwr NuxseRyZs9y9 EaPRUnpNDATE <br /> GEODMPMCALINFORMA rdinatoaX _Y Township_ Range_ Section_ <br /> w <br /> IHIFNOED USE omeatldPnvete buel ❑InduaMal O Water Quality Monitoring O Soil Sempl41p/Charadadzetlan <br /> em <br /> mm�R.a nom oM,.r r a <br /> TypeOFN:R IxNmWen C Replacement Wel O Wel Alteration(Modificeean CDOW <br /> a oraon� <br /> ❑MOM1odn0 WeN(a) i dwalls J Son Bodng(s) mew.,,. (I Gwlechniwi <br /> D Out-0l-Service Well U OuI.Of-Senlce Well Renewal O Croaa-Corviectlon Repair <br /> O New Pump O Pump Replacement 0 Pump Repair C Relae Wel Casl <br /> WELLCO"TRUETON <br /> Drilling Method)(Mud Rch ry O Air Rebry D Auger ]Cebis Tcol D Posh Point O Other <br /> Propased Well Depth 0b M1 eave9or,_- 40 in diameter -:I Open Bopom A(Grevel PeWGTavel Sire M In ft.W <br /> I Conducto Casing In chame[er I Conductor Casing Depth SA M1 <br /> Wall Ming Diameter n sage/ASTM Schad C Steel O PlaSUc C Stainless Steel 7 Olher <br /> GrggLS h at Cement(94)8 bag/&IO gal water) Sand Cement A9 deck ndd7 gel waw <br /> O antonll (2064 So Ids) O Other <br /> Grout Placement Method U Pumped Free Fall UOther ORetardent/Pmleralor(name) <br /> PEDESTAL Installed BY C Driller ]Pump Contractor O Other <br /> ❑Conemb Pedestal Dimenalona:Wdlh R Lerpm R Tblda M C Christy Boa C Stove Pipe <br /> PugP U SubmersibleC Turbine O Other HP Pune Set A SlarMklQ Walx Level M1 <br /> I HEREBY CERTIFY THAT 1 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 REWIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. - <br /> MINI M 24 HOUR ADVANCE NOTICE REOU D FOR INSPECTIONS <br /> SlW1ED TITIe DAIS <br /> t 3 <br /> 44+ <br /> D <br /> 14 <br /> I °I 1 <br /> DEPARTMENT USE ONLY <br /> r <br /> Application Accepted 8Del. ID 11U Area Employee lM Idouu' IL , <br /> Gmul Inspection By Data LIT/� 0 S WGII Permit ''- - <br /> Pump Inspection Sy Data 0 WAIVER Received <br /> Sol Boeing Inspection 8YIf Date DonawDlad W 1 Depth R <br /> COMMENTS U <br /> PE Recehad k Amount Date. Imokee YWglOs <br /> Cod" Info B RamKbd Service t/ <br /> 436q 1'80 ].11A� 1— t vo SR.C7 b�t�g0� <br /> So'u*0 a N£LLIPIMP PEAMR <br /> ,,owe <br />