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,"m .� WELUPUMPPERMIT <br /> `,Si,-JOAQIe1NC,OONTY ONMENTAL THDEPARf1EMT 600 EAST MATH SIP STOCKTON CA SS202-(208)433-3428 <br /> NON-REFUNDABLE PERMIT 'WI/ CALL 209 953-7697 FOR INSPECTIONS b.ARES 1 YEAR FROM DATE ISSUED <br /> 51000 � N <br /> JOB ADDRESS �.•, PA IL' Pk""aY C"Imp S4«,k4cs 951260 <br /> CROSSSTREET EalL%AHr)C AVG APN 177-2ko-2f PARCEL SIM LANDUSEAPPLICATIONM <br /> OWNER NAME C>#0 90SII 1 pp PHONE <br /> OWNER ADDRESS 66 rcmOkl;n 54tc Y, 54, --�s00 C"ISTATEMP Oa/C(wru//Co/ 94,607 <br /> CONTRACTOR I-"&fc Tnc_ PHONE (�'I) Q3T-OLro <br /> CONTRACTOR ADDRESS Soo N- LJrlw AVt I_ SIt, A. OVISTATFTP Rc Opnlj CA/9S3rL <br /> SUBCONTRACTOR wc5l• COss� NC'-� PHONE(2011 A38-9;OA <br /> SUBCOMTRACTORADDRESS Q-0. P.or 133 CITY/STATFJLP Esc.lovt ICA/9537v <br /> LICENSE 7(C-57 ❑CE1 ❑DDS UOther NUMBER pN7IaI 8(PIRA1nONDATE I-3I-a`I <br /> GEocwHICALINFORMATION: Coordinates% Y Township_ Range_ Section <br /> INTENDED USE ❑Domeslic/Private D Inlgation/Agricultural ❑Industrial 0 Water Quality Mon" ➢(SOI Sampling/Characterization <br /> M ❑Public Water Gystom <br /> 8 Public Tmm ostwmsrsynmrnA- <br /> TYPEOMWORK ❑New Well ❑Replacement Well O Well ASeration/MCEI3czllon D Other <br /> ❑Monitoring WelRal aulwelB ❑Soil Bodng(s) OarI vo$ xGeotechnical 10-1,11- <br /> J <br /> 0_17❑Out-0T-Service Well 0 Out-OfService Well Renewal 0 Cross-Connection RaPair <br /> ❑N.Pterrp D Pump Replacement ❑Pump Repair ❑Raise Wel Cash <br /> aV WELL CONSTRUCTION <br /> V2 Drilling Method D Mud Rotary ❑Atr Rotary Auger ❑Cable Tool ❑Push Point ❑ Other <br /> se <br /> Propod Wall Depth 10-10 R 11 <br /> Excavation_y In diameter ❑Open Bottom ❑Grswel P&ck/Gmvel Size x,dMunwsT <br /> ❑Conductor Casing Indwmeter / Conductor Casing Depth If <br /> Well Casing Diameter_in Thick,o,WG,uge/ASTM Schad ❑Steel ❑Plastic ❑Stemless Slee! ❑Other <br /> - Grout Seal Deplh R )(Neat Content(94 ID Daq B-10 gat water) ❑Sand Cement sack mix,`7 gal water <br /> V ❑Bentonite(20%solids) %Other Lv 1VA= <br /> Grout PlarwrlNnt Method ❑Pumped $Free Fal B;OUIer ❑Retardant/Acceleralor(name) <br /> 0/ PEDESTAL Insblbd By ❑Ddler ❑ Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimenalons'WIlth_E Length SThick In ❑Christy Box ❑Stow Pipe <br /> pg 1r�P D Submersible❑Turbine ❑Other. HP Pump Set R Standing Water Level 3 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> Z JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> w CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WTTN ALL <br /> WORKERS COMPENSATION LAWS. <br /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> BIOMED TITLE DATE I2/,{pI�g <br /> 0 <br /> NVf <br /> R <br /> _ <br /> ^.yr�a E/Pr�IARTMENT USE 9INILY <br /> Application Aocephod By. IC �(L Date 0 f/ Area Employee0114f /Qb <br /> Grout inspedbn By Date ❑ SPECIAL Well Parmlt f� <br /> Pump IDspeCtipn W Dale - ❑ WAIVER Received <br /> Soil Boring Ins cti By Date Constru tad II Depth K <br /> COM7N (7 <br /> L <br /> PE Sc Received Ch Aount ormW <br /> Codas Into B asmh Ramltted DataService uesta Involco0 Wall off <br /> 1 s� fr 06�q o 3 Der 6223 <br /> EHD46 µELL W1a1P PEPoIR <br /> aU1aIB <br />