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WELL/PUMP PERMIT <br /> SAN JOAONN C0uaI ENVIRONMENILL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTONCA95202 - <br /> NON-REFUNDABLE PERMIT (209) ISSUED <br /> I/� {--q .} �f,CALL <br /> L2r09 95q3-�76�97�FOR INSPECTIONS 1E'X�J%'RES'I YEAR FROM DATE ISSUED .]y <br /> JOBADDRESS �D2I nV,ASl �1f IU! a l/J (µ'yI�W {.YT+L/I <br /> CROSS STREET GUY K!J AVN Lft —4230- II PARCEL SI IW.•Of NOrUSE APPLICATIONR <br /> OWNER NAME IIITTT1^&y'P �I l r�1 PNONE <br /> OWNER ADDRESS (01 NAtt Q�glE a1r�p.,�L AlLt Q tmIBTATf2v �OL(A ^G'P IS O <br /> CONTRACTOR wed II O. /lI 1�JA1'Lt�WrI 1 T/L y�(J�atC SI I h f pHow 201 �07 —3701 <br /> CONNGCTORADDRESS •OZ I"CI1j S, r, ON Qct /-t y <br /> CmISTATEILP I—QG�.I VT <br /> SUBCOMRACTOR PHONE <br /> SUBCONTRACTDN AoME4 J` <br /> CmISTATEZP j y} <br /> LICENSE C-57 C-61 NMBERLgA W4 E....ONDATf IgI1r� <br /> GEOGRAPHICAL IWORMA N: l X I Y Tmnfhip_ Ranga_ Section_ <br /> IIREIIOED USE w« n1 Water Quality Monitoring Sdi Samp1.WChanh:erizetion <br /> PuW @ « <br /> neEp �u <br /> TYPE OF WORK New Well R reponIMod6cation Other <br /> Monitoring WIN($) ) fdwwa xGeotedlnkel eNaailnpa <br /> Cul-Of-Sernce Wel - ceVJM Ferretti i Cross-COnnadlOn Repair <br /> _ New Pump Ir Raise VdellCasi <br /> WELL CONSTRUCT ON <br /> Drilling Method MAR Rle7 Alr Rotary Y Auger Cable Tod Push PaIM Other <br /> Proposed Well Dept V-1 S l Excavation In diameter Open Bohm Gravel Pack/Gravel Site in diameter <br /> COndudor Cashg In diameter / Conductor Casing Depth l <br /> Well Ce.ing Diarneteryin ThlclmaWGa ge//ASSTM SDh,j ,,9 Steel Plastic Stainless Steel other <br /> Grout Seal Depptenion4e(20%saNda) 'Neat C}91�eraWC ba 1bl Y���rer) Sand Cement sack mire gal water <br /> (Grout Placement Method Pumped Free Fall Other, Retardant/Accelerator(name) <br /> PEDESTRL Installed By DrBer Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_11 Length M1Thlck in Christy Box St..Pip <br /> P. Sutm amble TuDine Other HP Purnpi.;t It StarM'ng Water Level M1 <br /> I HEREBY CERTIFY 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. <br /> MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS Q Q <br /> SIGNED TIT DATE <br /> Z <br /> 10 <br /> S <br /> D p <br /> P <br /> KiNte' Kelllam n t7 �P <br /> di o�. 41 <br /> N�ajfh�?sp 011 <br /> LO N <br /> L <br /> T ErR <br /> ` •p RTMENT U� <br /> E/�p,�N•LY <br /> Application Accepted B•'� �v:` I DArean �V�•-'•V Employee l .Yef <br /> Grout Inspection By Date - SPECIAL Wall Permit <br /> Pump Inspection By Date_ WAIVER Received <br /> Soil Bonnig!9ppeopon By Data Cons uo Wall Depth N <br /> COn//N/''M�E/E/JJ.I,.TS <br /> /j <br /> PE SC Received Amount Dela Permiti Involve9 Wel RN <br /> Code. Into B ash Re TIVild Servile Request B <br /> EMU�]� WELL NUMC PERMII <br /> BFVOC <br />