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V 'LL / PUMP PERMIT <br /> IOAQUINCOUNTtENVIRONMENTAL HEALTII DEPART!R 304E WEBER AVE 3°`,STOCKTON CA 95282 - (209)468-3420 <br /> JN-REFUNDABLE:PERMI"1 J- y L+� (AI.1• 209 9$3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn <br /> CITY/ZIP <br /> L o-0 <br /> JOB ADUNENS �l <br /> 6&"- <br /> /1l�t//��/I��I,r,]73�- ARCEL SIZE LAND USE APPLICATION# / �'4 — <br /> CROSS S"I RI.F.t lr&"- <br /> PIIONE <br /> Oss'NEN NAMI. �LI(.I/j•Ej� <br /> CITV/S'TAT'EIZIP <br /> OWNERAUDNEFS - <br /> PBONE <br /> CONrRA(TOR 4-cti - I'/S'I'Al'tYZIPCONIRAl-Il1RADI1Rf:CS <br /> PHONE <br /> StB('ONTNA(-IOR <br /> CITVISTATE/ZIP <br /> SOBCONTRA(TOR ADDRESS <br /> e <br /> LI(IT"NSF. '-57 ❑C-61 ❑D-09 13 Other NUMBEN EXPIRATION DATE <br /> ), Township _ Range Section_ <br /> (i EOCRAPHR At.INIO2—ell <br /> .TI(1N: Coordinates <br /> INI IrADEST. Rnncsuc/Pnvum ❑Irrigation/Agricultural ❑Industrial 0 Water Quality Monitoring [3 soil Sampling/Characurization <br /> U LI <br /> ❑Public Water System ager yslcm 3montaa eme or one um r <br /> fd.ffcrcnr from )-nee <br /> TV PE OF WORK O New Well ❑Replacement Well ❑Well Alteration/Modification #of O1Tbest Hole ❑Other p afbonn6rs <br /> #of wells ❑Soil Boring(s) ❑Geotechnical <br /> ❑Monitoring ctio ❑Out-O(-Service Well Renewal <br /> ❑yGell Destnclionn ❑Out-Of-Service Well <br /> ew Pum um Re lacement ❑Pum R air <br /> ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth fl Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> WeII Casing Diameter _in Thickness/Gauge/ASTM Sched sack mix/7 gal water <br /> R ❑Neat Cement(94 lb hug/5-10 gal water) ❑Sand Cement <br /> Grout Seal 0 Be ❑Specs on File ❑Specs Submitted <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name I� PN, <br /> ❑Retardant/Accelerator(name) 1 I 1 <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other , <br /> Pl:IIf:XI'nt. Installed By ❑Driller ❑Pump Contractor <br /> ❑Other <br /> in ❑Christy Box ❑Stove Pipe <br /> ❑Co do Pedeslal Dinicusinns; Width _ It Length 11 Thick <br /> 1'Ef1I• LKuhnicrml,le ❑Turbine ❑Other-_ <br /> {lp Pump Sct B Standing Water Level <br /> I III RIIt\' LERI IF\' '1lln'f 1 IIM F. PREPARED "IIIIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> unVt tN t (WI N'IV' ORDt:IN%%('I N STAI1_VAAN <br /> 'S, AND Rl'LES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> t 1 Rlti NI AND IIAI. )!Illi 1111. (AI"IIORNIA (ONIRA(-IRAIOBS SLATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL �r <br /> %%OR61.R,(O I' -NSA11//N I.A% ^S <br /> 1111 IUM 4 HOUR ADVANCE NOTICE I .Q IR :D FOR INSPECTIONS �r <br /> TITLE DATE/,00 <br /> TITLE �L/ <br /> NILNlU <br /> 1 <br /> SA J A UI OLIN I <br /> M "N <br /> it <br /> r � <br /> DE PA RT M E NI' USE ONLY / <br /> Date /0 !l (%� Area Employee ID# 5"3 b b yC. <br /> Application Accepted By <br /> Dale [3 SPECIAL Well Permit <br /> Grout Inspection 13y '+ <br /> Pump Inspect n By :J -� ❑ WAIVER Received <br /> o - Date Constructed Well Depth it <br /> Destruction Inspection y <br /> COMMENTS - <br /> -J <br /> / Amount Permit/ Invoice# %sell lD# <br /> PE SC Received Choc Date Service Re nest# <br /> Codes Info B Cash Remitted <br /> y;..til U:A.• a 1. �C..(?V (1D k\ OS <br /> -u i m ur rI a so I <br /> HID43-02-M, <br /> X.r,04 <br />