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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)458-3420 <br /> NON-REFUNDABLE PERMIT 1 CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS -18 J 1 E %tif t'11 H SOh I� 14grY� <br /> 1� ^ l Q CITrlCP I �,. c.. q 5 337 $s <br /> CROSSSTNEUN'SI;e tZ-,/� APN jLS-t'2.V6'4$ PARCEL 82E r�LAND USE APPUCATIONa <br /> OWNER NAME )1[�PIrS VqA ,1 t <Yt <br /> MaSIl11 <br /> PHONNE652.- 117 <br /> " CITYISTATEMP�A w�'OWNER ADMEN LL <br /> CONTRACTOR O.-TIIINr 7-ht, PHONE S?-i- I91-1213CORACTOnAcMass; 1k4 &164h yX <br /> 5337 <br /> IN9 <br /> j7. CITY/STATS(LP MO[I rik CG GC7(7� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATEMP <br /> LkENBE )(C-57 C-61 i 0.09 Other NUMBER b 6��L]_ EXPIRATION <br /> GEDORAP111CALINFORMATION: COOrdlnat"X Y Township_ Range_ Section_ <br /> INTENDED USE Domestic/Pdvete AIndgationtAgricultural Industrial Water Quality MoNtodng Soil Sampling/Chamcterizetlon <br /> PudueCemhomrihme�mWe yNemNama Doled aowW e <br /> TYPE OF WORK(NEW Well Replacement Well Well Alteration/Modification :Other <br /> Monitoring Wells) aof wells Soll Barings) YO1 pp°"p' ¢Geoischnlcal e01b in, <br /> Out-Ol-Service Well Out-Of-Service Well Renewal CrOSS-Connection Repair <br /> 'Now PUTp Pump Replacement I PUMP Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method>(Mud Rotary I Air Rotary -Auger I Cable Tool Push Point I I Other <br /> Proposed Well Depth4160 r <br /> k Excavation d;` <br /> In diameter Open BOaOm )(Gravel PecWGravel Siz in diameter <br /> rt Concllwlor Casing In diameter / Conductor Casing Depth h <br /> Well Casing DiameterUp In ThIckness/GaugWASTM Schad 61 Se D y Steel Plastic - Stainless Steel Other <br /> Grout Seel Depth 50 K Neat Cement(94 lb bapS-10 gel water) )Send Cement/0, 3 sack naA7 gal Water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ed Free Fell -Other Retardant/Accelerator(name) <br /> ELOLSTAL Installed By '__ Driller Pump Contractor - Other <br /> Concfota Pedestal Dimensions:Wdth_h Lenglh X Thick In Christy Box Stove Pipe <br /> PUMP Submersible,-.Turbine Other HP Pump Set ft Shanding Water Level it <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 /> MMMIU�M1244.HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED �ovl, ��� TITRE P-!ML l I r✓ DATE S- <br /> hi <br /> IF— <br /> A 7 M <br /> Ulu— <br /> TAtsLf(S'! TMENT USE ONLY S MFM' <br /> Application Accepted By isS110114, Area / 9 9 Employee 113 <br /> Grout InsDeCtbn By Date G 2 ❑ SPECIAL WeII PeTTIT <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Bonn g Ins By _Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eckk Amount Data Service <br /> Invoice Well Do <br /> Codes Into B as Remitted Service Ra uest a <br /> 43h! 3TF(-n1 54,)4 %" l Pl 7. <br />