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WELLIPUMP PERMIT <br /> SANJOAO0&COUNTY EAn RONMENTAL HEALTH DEPARIMENT 600 EAST MAIN STREET-STOCKTON CA 9510I-(209)4683120 <br /> NON-REFUNDABLE PERMIT CALL 209 953,--7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS .27SAl- 1Ll�ilf/ �' `� Cm2P O 95Zf°i7 <br /> Caoss STREET /L fZ7,,1- 9 JEn3—//yYO��OT,7PAI�EL SIEd L.USEAMLI¢ATRINpp <br /> OWNER NAME 0ZFj V/TA' // 'I GLV PIIOIE <br /> OWNER ADDRII /RO, lel ~C/V/CO CRYISTATE/LP 44y41 120- <br /> CONTRACTOR /'/SOR�/��� "" _ �PHONE /A�`'—Q�Lr� ✓ <br /> CONTRACTOR ADDREaa ��jJ Cltt/STATE21P <br /> SUScO CTW �/� -"/S O101A. ✓" PHONE <br /> SYaOOMTRAcIdIADOR[a1 CRYISTATEZP <br /> uceNae 571 ❑PUD D Other Nuesea gW1 ZZ ExHIRATIGN DATE <br /> BEOgtUFIKAl t1PplMATIW: Coordir&NEX _ r ToWREMP_ Range_ Section <br /> INTENoeo USE ^DomestiOrPrlvate n IMgaffWAgrlwituu�r//al O Industrial D Water Quality Monitoring C Soil SamplinglCnarader'iration <br /> OY Public Waateer System �07�/d If�rr nRw u <br /> TYPE Of WORN/n New Wall XReplacernent Well D Well AlteretiordMOdif 2lim ❑Otner <br /> n Monitoring Wella) sof Melts ❑Soil Boring(s) SOW,. ❑ Gaoteonnlcal rer vannas <br /> n Out�(SerWCe Well ❑Out-Of-Sen loe Well ReneMal O Cmss-Connection Repair _ <br /> New Pum ❑ <br /> Pump Replacement O Pump Repair ❑ Raise Well Cisingw 1 <br /> N <br /> Drilling Method K4 Rotary O Air Rotary ❑Alper El Cable Tool Ll Push Print ❑ Omer <br /> Proposed We Depth ZOO R E...bVh__L�'_In diameter a Open Bolton _A�Mra I Pack Gm"l Size Y in diameter <br /> -.ConduclwppGakq In diameter I Cattl Depth-ft <br /> Wall Casing Oiameler-gin Thidmess1GaugWASTMSC /-� Steel�,Alaatic DStwnlessSteel LOmer E, <br /> Grout Seal Depth zGn N (I Nest Cement(91 ID oag/5.10 gel Wafer) *%and Cement le-3 Beck mir4 gal Mater I J\ <br /> r Bentonite(20%50113) O Omer <br /> Grout Placement Method ped ❑ Free Fell O Other ❑Retardant I Accelerator(name) _ <br /> PEDEetk Installed Sy Driller dlPlmlp Contractor 7 Omer <br /> n cota atl tel DlydYmlena'WMm _it Lsngm fl ThIck In ❑Chrlsty Soo O Stove Plpe <br /> P Dm rsible^TuMhw, D Omer HP Pump Set fl Sbntling WetR Laval fl <br /> 1 HEREBY C RTiFY 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 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. r� <br /> MI Q j�A/�/VVA,NNCCEE NOTICE REQUIRED FOR INSP_ECT�)O/(SS-P�LE�ASE CALL(209)958 76 7 <br /> SIGNED /(fY//i/i^i�` MILE �CP:/ DAR ""// I <br /> / I <br /> L1 11111 per I <br /> IN I <br /> 201 AV <br /> - <br /> .IY <br /> N JOAOL IN N 11 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By -.• .._ _DWe —owe"" Anse GC.V Illi ErnplolMa IDs 5e3vo i49 <br /> Grout bupectior ey Date.�,�o ❑ SPECIAL Well PermR. <br /> Pump Inspection By u Dan ❑ WAIVER Received <br /> Soil Boring Inspection By Date Ccrlstrutl d Well Depth R <br /> COMMENTS n <br /> PE 9C Racehred Amount Data Perm IV Invaloee Wee lot <br /> Coda Into BY Cash �LRammed Service Ra W41111111 <br /> 4&rol OSI 1 1r ROO(o0/0 <br /> �a...a. vn3LIBV Pawn <br />