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WELUPUMP PERMIT <br /> SAN JOAQdH COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA I.TON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFl/NDASLE PERMIT CALL(209)953.7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB AOORESS /-AONs Uwo-'Ow— IU'SR_ CmILP '✓`M��'�'R L-+A qSS�� D <br /> A <br /> CROSa STREET APN ]Z LD] D �R PARCHLSIZE_yL=LANG USE APPDCATIOxi <br /> ONNER NAME 16r-tip AtVR�T- PNONE 201 <br /> OWNER AOpne96 Cm/STATFRIP <br /> CONTRACTOR V A-✓'��K'h'+y 1.t1✓�s�1u��•y^' PNcNE <br /> GONTMCTLR ADrNiE95 L4 101 Cml$TANF2IP wlhrY2,� A <br /> SURCONm11cTOR PNS <br /> SUBCONTRACTOR ADDRESS CmISTATEZP <br /> 4CEMEE C'ST C-61 :t D-09 IOther�' A- NUMBER !Ej=S7 EKPMAtgN DATE 7 1 <br /> GEOGRAPHICAL INFORMAIKIN: Coordinates% Y ToWIremP_ Range_ Sectbn_ <br /> INNTENbEDUSE OornestKlPrHala ;i lNlgatioNAgricu0Uml :.:Industrial Water OualNy Monitoring t!Soil Sampnng/Charademuttion <br /> '.'Public Water System <br /> M 4MwaX trap ORmr. <br /> TYPE OF WbRK New Well -_i ReplecemerM Web ! Wetl ARerationlMaditltelgn C Other <br /> Monitoring Wallis) sol wells l..Soil eonng(s) ad swags C�oleUnkal smeary% <br /> 1M'=-D,' a—Weil I t Out-CN-Service Well Renewal J Cross-ConmeRon Repan <br /> / NMM Pum P Replacement TI Pump Repel r_ Q Rake Web Cas ___ <br /> WEtt Cp19TRMLMR! <br /> Ddning Method Mud Rotary J AR Rotary Auger ,Cable Tool l Push Point U Other <br /> Proposad Well Depen—ft Excavation In diameter IOpen Bosom Gavel Pack/Gravel Sae In diameter <br /> Conductor Casmg In diameter I Conductor Casing Depth R <br /> Well Casing Diameter_in Thi .sslGauge/ASTM SChed I-Steel 1:-PMMIC Slatnless Steel Other <br /> Grout Seal Depth it Heal Cement(94/e bays 10001 wAnTO ']Sand Cement sad,mull gal Paler <br /> Bentonae(20%WIAS) Other <br /> �Orout PlacemelM MetlNld "..Pranged I Free Feil 1:.Omer _ : Retardant/Accelerator(marine) <br /> IPraxcsru InataIlNl By [�Pedestal <br /> Ile:/mPummW <br /> p ifth Ltor Order <br /> i. CornerM aPatlestal ONb <br /> :WidDI_R Length—ft inirA in n ehrtsry Box I Stove Pipe <br /> jepj�_......Submersible:-'Turbine 'IOther HP_„ Pump Set R Standing Water Level R <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. 1 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 THIN UWS. <br /> ITT24 HOUR ADVANCE NOTICE REQUIRED FOR I PECTIONS-PLEASE CALL(2D9)95 <br /> t _ _ __ _ - <br /> lift iuifi <br /> DEPARTMENT USE ONLY - <br /> Application Accepted By i4--C Date AreaErnpoyse tDi T Q P R'103 <br /> Grout Inspection By _ Date t11ip t SPECML Well PeFRIIt <br /> pump Inspec0on B ��,vL reRla 17 <br /> [1 WAIVER Received <br /> Soo BOMB Inspection By Date Constructed Wan Depth R <br /> CO NTS I <br /> PE Sc Recelved C k*1 Amount Date Pill III Imolos0 _-_ Wall <br /> Codes ' RwniMed _ _ SOMM Ra le <br /> .W �_LS81- toSo� llrQ 133,�OOloBS// -- <br /> END a3d5 NELL PUMP PERMIT <br /> �2 <br />