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WELL/PUMP PERMT 00 <br /> SAN JOAQUIN COMM ENVIRONMENTAL HEALTH DEPAWMEM 300E WEBER ATE 3-FL-STOCKTON CA 95202 -(309)4663470 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRECR - N•/-zCA �� CITYfLIP /rUfr�� <br /> Q <br /> /- <br /> CROSS STREET ��S ) ( APN ��V//L' J PARCEL SM.�I9_AND USE APPLICATION N �A V <br /> CW ERNAME PHONE 045 <br /> ! <br /> OWNERADDREs-S .73IN2 / kjac5-f—, CTFYISTATEJZIP <br /> CONTRACTOR 77 S[Py G LSL/ Rd, <br /> fa yP1H/jONE✓22�, <br /> CONTRACTOR ADDRESS I / 41beNS M a CITvfSTATE21P � w/D a-'.& C�- <br /> SUBCONTRACTOR PH:FwL <br /> SUBCONTRACTOR ABBRESS CITYISTATEILIP <br /> Ltuxs[ 04c,-57 OC-61 13D-09 El Other NUMBE 2 EXPIRATION DAEZ©O <br /> GEOGRAPHICAL INFORMATION: Coa dinates X V Township_ Range_ Section_ <br /> INTENDEDUSE pef.DunesvidPrivare D 1OigetiWAgriculturel ❑Industrial D Wow Quality Monimling ❑Bail SamplinIsChmacterintion Q <br /> ❑Public Water syysstem <br /> Haiti trmm Qum. nun Htm matt amew um <br /> TYPE OF WORK A--well Well D RepUc scent Wall ❑Well Alu ation/Modificadon O Tat Hole r!Other <br /> 13xartaanst <br /> Monitoring Weli(s)_4 ofwells ❑Soit Boringr.Owra g+ <br /> s) DCatahninl <br /> D Well Dvahrocbon D Out-OfScnice Well ❑Ou64X-Service Well Rented <br /> ❑New purne ❑Pump R kcement D Pomp Repair ❑CmsS CAnneCDan Repair <br /> WELL <br /> N` U �M <br /> R?e E ft ir RouO AHo <br /> Drilling <br /> Tt O Pusfi print ❑Other <br /> ProposedWeoE .6. m diameter <br /> D Open Bottom ❑Gnvel Pack I Gravel She in dinrcsR <br /> D Conducmr g ud'utne / Cond//ucCasing Depth ft <br /> Wait Casing Dianne., in ThioiuH..raugdASTMSMod el!mrO ❑Steel A lwie 17 Suioloss Steel 13Othtt <br /> Grout Seal Depth A%9 it ❑Nat Cemal(941hhag15-10w1-ufer) ❑Sand Cement suck marl 7 gal vaster <br /> Dict.twite(20%wilds) OManulh=mr Spec%solids_% Name_ DSpaeson File DSP.Submirud <br /> Groat Placement Method O Pumped ❑Fra F&U D Other ❑RdardM/Accelerate(name) <br /> PEDESTAL Installed By ❑Driller mp C..W.Wr ❑Other <br /> D Conerete Pede" Dimeedana; Width R Length_R Thick in O ChrletyHex O Stove Pipe <br /> PUMP ❑Submersible ❑Turbine DO&a HP_ Pump Ser ft Standing Wawl. yc! R <br /> WELL DESrlt L ION ❑Open Bottom ❑Gravel Pack DUncaed ❑Other <br /> Wet]Diametc+_n TOMI Depth R Depth m W.lm ft D CaSieg W k Perfomled(mm_R m ft <br /> Sealing Material O Now.Cement(94 lb bagl5-10gd/ ler) ❑Sand Cement sack mix 17 gal water D Beownite Pellets <br /> D Bamnde(20%solids) ❑Manuf.cv w Spm%solids % Name D Spers on File ❑Spars Submitted <br /> Placemen[Method ❑Pumped ❑Fra Fall ❑Other <br /> D Complete with Mushroom Cap R below grade D Complete m Existing Surface Pad <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> ,�I�JM�INIMOUfM 224 HOUR ADVANCE NOTICE\REQ/UIRED FOR INSPECTIONS <br /> SIGNED L/r i J e rJ.sP& TITLE 1 F-lll�"r DATE <br /> NN <br /> rl <br /> A UI <br /> i VI N <br /> Try E <br /> it <br /> I <br /> EPARTMENT USENLY �T <br /> Application AcceplW / Dam it (- Arra eC/ Romkree IDY'Z&7 ap � <br /> Grout Ins to L-a'l DnY� /Qi ❑ SPECIAL Well P2Em1l <br /> Pump tnspcou-By Dam ❑ WAIVER Received <br /> Deswcdon Inspersion By Dau Constructed Well Dep&_ R <br /> COMMENTS <br /> PE SC Received Cheekg Amount Dau ec IBvakeB Wall IUM <br /> Cada Inia H n Rearmed ServkeReq Baste <br /> 7 DZ 2.Z 6 0 ' Rao •-159 1. k L,PCczj n� <br />