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i <br /> WELUPUMP PERMIT l ) <- <br /> SAN JOAOum COUNTY ENYLRONMENTAL h-LTH DEPARTMENT BOO EAST MAIN STREET,=STOCKTON CA 95202-(209)488-$420 i <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> l <br /> JOB ADw:€sa ,��3a� a'tl �'4s.7iLt�e-n.o�T1C1� CITrfZI/P L-,,g1CSrnr2j 9%.---L a <br /> y <br /> tiRass 8TREErfle�i�7�.cs n APH dsr-3 10-fPARCEL SIZE r" LJVIO USE APPLICATION N b <br /> OWNERNAM19 3' PHONE S-IkgS S. -Om4 <br /> OWNER ADDRESS 'S-A.M 1.Q. _ - CITYISTATEMP - <br /> CONTRACTOR Q PHONE <br /> CONTRACTOR ADDRESS 43g pt- X - {AI %t -n-V- CITY/STATEMP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CLrYISTATEIZIP t <br /> - t <br /> WCENSE T 1 n D-09 ❑Other Numzrit Exput TION DATE <br /> GEOORAPHICAIINPORMATION: Coordinates X Y Township„ Range Section <br /> INTENDED Use n DomestictPrivate 0 IrrlgaborUAg6cuitural ❑Industrial O Water Quality Monitoring 0 Sal Sampling/Characterization <br /> ❑Public Water System <br /> If dHfarent tom Ownx r m ame arra or Phone u <br /> TYPE OF WORK ❑New Well 0 Replacement Well 0 Well Alteration/Modif cation 0 Other <br /> 0 McnitoringWell(s) #ofwells p ScilBoring(s) 0ofburings 0 Geotechnical °ofeoroee <br /> 0 Out-Of-SeMoo Well 0 Out-OfSer 466,Well Renewal G Cross-Connection Repair <br /> 6 New Pump eumpReplacement t7 Pump Repair q/] <br /> WELL CO}iSTRUL"T1ON W <br /> Drilling Method 0 Mud Rotary ❑Air Rotary 0 Auger 0 Cable Tool n Push Point D Other <br /> I Proposed Well Depth ft Excavation in diameter C Open Bottom ❑Gravel PacwGravel Size In diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diametar_in ThIrknesslGauge/ASTM Sched 0 Steel ❑Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth It 0 Neat Cement(941b bag5-10 gal wafer) 0 Sand Cement sackmir/T gal water <br /> n Bentonite(20%solids) ID Other <br /> (Grout Placement Method C Pumped ❑ Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor o Other <br /> D Concrete Pedestal DlmensIws:Wldth ft Length ft ThIck in ❑Christy Box 0 Stove Pipe <br /> Lggm�p___­ ubmaralble❑Turbine ❑Other HP Pump S It. Standing Water Leval ft <br /> { I HERESY 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 /> NIMUM Z4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> i - - <br /> rut 0 <br /> I <br /> k <br /> f <br /> R <br /> SAA if pa lit Lub <br /> N RC N AL <br /> DEPARTMENT US`E ONLY ca <br /> Application Accepted By-- Date D 0 8' Area Employee lDtl jZj(g I[� <br /> I Grout Inspection 8y Data ❑ SPECIAL Well Permit <br /> Pump Inspeedon B Date <br /> IRT- ❑ WAIVERReceived <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS- <br /> PE <br /> PE SC Recelved. Amount Date PermIU Irnolce# W81110# <br /> Codes info B Remitted Sarvi= nest# <br /> r2mr <br /> sr28R1Ta <br /> WELLMLIMPPERMIT <br />