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WELL 'oUMp PERMIT <br /> SAN JOAQUIN COUMT ENVIRONMEMAL HEALTH DEPARTMENT 304E WEBER AVE 3-FL-STOCHTON CA 952 09)468-3420 <br /> NON-REFUNDABLE PERMI�T� CALL((2�7e'�e <br /> 3-776697 FOR INSPECTIONS EXPIRES 1 YEAR FROM1TDATE ISSUEDJUBA...ESS ��✓- 'T]I CDY/LIP ��/ ����� OCRO55 g'1'RELTn ,11�A (., // / 2-GO-01' PARCCL SI9& O./ LAND USE APPLICATIONX <br /> OWNER NAME W-f/ /IJ(ION CdZ /Aaq I w / PRONE _ <br /> OwNERADDRE9S /J O/ Cr,.w,M I'm Or. 5f I3/ Cm'/STATEIZIP //k1dcS V(4 9r7, jJ <br /> CONTMCrORd 1 C4 4(t. -J,,l./1 PHO�NEE l <br /> CONTRACTOR ADDRESS `IsSTNT r-P 4 C CrrY/SI'ATPITAP //�'r Cl CI�IvYZ <br /> SUBCONTRACTOR PHONE <br /> SuarxI PWCTOR ADDRES4 CT'/STATE/ZIP <br /> J � <br /> LICENSE 0C-$7 ❑Cfil ❑D09 ❑Other NUMBER E%MRKDONDATL <br /> GEOGRAPHKALINPORMATION: COerdlnatp x Y Township_ Range_ Sudan— <br /> INTENDED USE ❑DomeetidPrivate ❑IrdgotiONAgricultural ❑Indu.tnal .❑Water Quality Monitoring ❑Sail Sampling/Cnuscterintim <br /> ❑Public Water System �� onK <br /> Rdiff—, rn Owns. Ya '. .me .t u <br /> TVPE OF WORK ❑New Well ❑Replaceomt Well ❑Well AlteutiotVMedification 13 Other <br /> ❑Madmring Well(.) Xof wells ❑Sail Borings) xolaarnue ❑Geotechnical xarlpringe <br /> ,4T(5�t'44-Service Well ❑Out-0f-Service Well Renewal ❑CmaaC.roecticn Repair <br /> ❑New Purnp ❑Pump Re,laccurent ❑Puterp Repair <br /> WELLCONSTRUCr10N <br /> Drilling Method ❑Mud He ary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point O Dotter <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bailout ❑Gavel Pack/Gravel Sitt in diameter <br /> ❑Conductor Casing indiameter / Cooductor,Casing Depth ft <br /> Well Casing Diameter_in Thickrue/Gauge/ASTM Schell ❑Steel ❑Finnic O Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 1b bag/J-10 gat water) ❑Sand Cement suck mu/7 pal waW '4 <br /> ❑Bentonite QVA solids) ❑Manufacturer Spec%solids % Nome ❑Specs oo File ❑Spas Submined nt <br /> Grout Placement Method ❑Pumped ❑Fra Fell ❑Other ❑Retardant/Accelerator(name) <br /> PEpglrr� Inalaled By ❑Driller ❑pump Contractor ❑ Other <br /> ❑Concrete PedeHal Dimeabns:Width it E.englh ft Thick is ❑Christy Bos ❑Stove Pipe <br /> PUMP ❑Submersible O Turbine ❑Omer HP Pump Set It Standing Wamr Level fl <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 ]C <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL �+ <br /> WORKS COMPENSATION LAWS. ` <br /> I IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSP CTIONS <br /> SIGIeLD •ITTLL V C'wJ a(.� ✓tom DATE <br /> O� <br /> Y1 L <br /> -441 1 <br /> IV <br /> \7 <br /> l <br /> O <br /> DEPARTMENT USE ONLY ENVIRONME ENT <br /> HEALTH DEPARTM <br /> Applicadon Accepted By Date 9'/2,10-7 A. Employee IDX <br /> Grain Inspeenon By Data q 'x' 13 SPECIAL Well Permit <br /> Pump laspoetiou Date J % ❑ WAIVER Received <br /> Contracted Wall Depth B <br /> COMMENTS l.Z2ae`<1/ 9 7'7 L ri'J / //I!)�1� I I� //.aLa tt.w <br /> J s Y`,l Le4Ae7a. u tD <br /> PE SC Reedved Chordal Amount Date PerMV InvelttX We111DX <br /> C.d. Into B Cash Remifted ServiceR until <br /> 3F. /78' 5- 1 /�c..ry d 5 �' <br /> BRI WELL PUMPPFAMIT <br /> IM4,10l <br />