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�� •,� ` WELL/PUMP PERMIT 116. <br /> SAN JOAQUIN COUNTr��x,v.��,NMENTAL HF_AL'1U D£PARTALE[17' <br /> -"''-'Y 600 E.MRIs Street.SIYICICrON CA 95202-(249)468d420 ' <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOIL INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 3OBADUREssAD p - 1, CITxIZIP <br /> CROSS STREET I T�E�R R 0. AM Oil^/(10-15 PARCEL 5175E B 7 ?USE AM tCA7TON N <br /> ownEnNAM 1261i' .,ia Gu 15 PHONE 83fn-e7 -32 re <br /> OWNER ADDRP.SS la4 ,S T .ST. _ CTry/SrATTtW P•4'7 MSaa7 <br /> CoNTP-4croiz _ Deka Pump .- - Poom.204-466--905_- <br /> 0ONTRACTORADDRm 646 S. California Street CTIMMATFJ4:R Stockton- CA 2 <br /> 03 <br /> SUBCONTRACTOR. PHONE <br /> SUBCONTRACTOR ADDRzss LT[I,ISI•ATE ZZP . <br /> LICMSs ❑C-57 XX"I' 13 D-09 I]OtkcrNUMBER - 724778 HXM$A77ON DAT$ _ BIO$ <br /> GEOCRAPHICALINFORMATTONr Coordinates X - 'X Township;- Range Seetloa_ <br /> INTENDED U g Domestic/Private D lrrigatioa/Agdculturs ❑Industrial 0 Water QtWity Monitoring ❑SoilSa npliBg/ChAmCterizatioB <br /> O Public Water System <br /> Ifdarmd from Oxine, atmryn= ameyr a vin <br /> F j j OR WORx 13 New Well . 0 Replacement Well 0 Well Aihration/Modirwabon Cl Other <br /> ❑Monitoring 1Ve11(s) N of wain 17 Soil Boring(s) a of t p°iup ❑Geateecbnieal a ortwr ags <br /> q Out,O&Serviee Well 17 Our-Of-Service Well Renewal O'Ctaes-Eannovilon Repair <br /> ew Pu O Re Irwemmt Pu it - <br /> 1 � ' <br /> Drilling Method 13 Mud Rotary E3Air Rotary 13Auger 13Cable Tao] - E3 Push Point 0 Other ~ <br /> Proposed Well Depth 11 ' Excavation 'in diameter 17 Open BoUcum 0 Gravel Pack/Gravel SizeCIP <br /> is diamettr- <br /> r 0 Conductor Casing in diameter I Conductor Cuing Depth ft <br /> Well Casing Diamacr_„-`in 7bickncs$10auge/ASTM Sched O Stm] ❑Plastic 0 Stainless Steel Cl Other <br /> Grout Seal Depth ft D Neat Comsat(Y4 16 bag/5-10 ga)warer) 0 Send Cement sok mir 17 gal water <br /> 1 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Spas on File 1]Specs Submitted <br /> 1 Grout Placement Method LI - <br /> Pumped ❑Pree Pall 0 Other ❑Retardatd%Acceietator(Dame) <br /> IRatalled By 0 Driller 0 Pump Cantrwtor 0 Other <br /> E ❑Concrete Pedestal Dlrrteuelaas:Width ftLength ft Thick N 0 Christy Bos ❑Stave Pipe <br /> Dua JtSubmersible U Turbine D Other HP Set It Stan" Water karst ft <br /> I 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 AM REGULATIONS.'I ALSO CERTIPH <br /> Y 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 /> t M 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TrJLE CEO <br /> DATE <br /> 3 <br /> ETTT <br /> i <br /> M <br /> i <br /> t. <br /> r <br /> 7 <br /> a... 4 <br /> - DEPARTMENT USE. ONLY - rL <br /> Application Accepted By Date 62i/0-7 Am Employee IDN <br /> Grout Inspection BY Date 0 SPECIAL Well Permit <br /> Pump Inspection mems , � Date. . %.-O 07 0 WAIVER Received <br /> 4 Constructed well Depth B <br /> PE SC Received Cheeldf/ Amobnt Permit/ <br /> Coda Info' H Cash Remitted Date ,Service7�ActineAN Invoke N well IDN <br /> c <br />