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/4175010 zrk�Ew� it ' -16 q <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 196E EAST HA LTON AVENUE-STOCKTON CA 95205-(209)4$&1420 <br /> NON-REFUNDABLE 1W Al <br /> S RC,A./,1LL 209 953.7697 FOR INSPECTIONS .1NEXPIRES 1 YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS 1W A A4a •er�l c1fzP <br /> CROSSSTREET Y_. FrCr1011 St ARM Iln-SO-I3 PARCEL SUE j ±IfLAND USE APIKICATIONN <br /> OWNER NAME IIMc!'C7L II��Nq'Lll f; Lot iPIONE <br /> OWNER ADDRESS V_;0 <br /> 1r �/ , pr "•Q jj I3 q CRYISTATEf21P Sl�h)'cn C4 5S Z07 <br /> CONTRACTOR Nal 0' /�IMIP�] S R l l errgr'On/ PHONE <br /> CONTRACTOR AODResan 4 GN CRY/STATE(OP /�'ll/{^ <br /> SUa60NTRACTOR N/I'�/�/ PHONE Al <br /> SUBCONTRACTOR ADDRESS / I CT'IasSTATEZP Ajl/ ] <br /> LICENSE X C-57 C-61 D-09 Othef NUMBER 104 EXRArON DATe '1/-r1�) ZU)r <br /> GEOGRAPHICAL INFORMATION: COOhBm SSS Y TBWnshIP— Range_ Section_ <br /> INTEKDEDU9E DOmesficlPri"Ie Imga9an/AgHwItural Industrial - Water Duality Mongorng ASdISamOfing/Characlerizadon <br /> Public Water System re 015 <br /> N n"..M lmm ONoer ear ye em ams <br /> TYPE OF WORK New Well Replacement Well We NAlte29onmodlfiralion Other so h <br /> rs <br /> Monitoring Well($)_0 of wells Soil BDdng(s) Pa lwd'g yGeoterhnlcsl� <br /> Out-Of-Service Well OutAlServke Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Galin <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary XAuger Cable Toil Push Point Other <br /> Proposed Wall Depth "2,0 h Excavation�_in diameter Open SoRom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth h <br /> Well Casing Diameter_m Thickness/Gauge/ASTM SChed Steel Plastic Stainless Steel Other <br /> Grout Seal Depth R Neal Cement 9albba93-1OgeIW8f*`) Sand Cement sock mtd7 gal water <br /> Senlomite(20%solids) �(Olhr Sat' ewl-1'nr ., be'rfn'�s Linder C'Kwrek C �fd%.� p,d <br /> Grout Placement Method Pumped Frac Fall than, Relerdant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contracror Other <br /> Concrete Pedestal Dimensions:Width_R Len; RThkk k Christy Box StOvs PIP* <br /> PANT, Subrmenoble Turbine Omer HP Pump Set R Standing Water Level it <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI U 24 VO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TrrtE f.n i n Ca( DATE <br /> w� <br /> o' <br /> x <br /> DE4P ARTMENT 8 ONLY <br /> I Dale' Area "1 Employee 100 <br /> Application Awepled �JCU,L U <br /> Inspection BY Dale - SPECIAL Well Permit <br /> Grout <br /> WAIVER Received <br /> Pump Inspection BY Date C <br /> Date Construetetl Well Dsp it <br /> Soil Boring IssspeWon BY 4 1� / <br /> COMMENTS 4jl& )L D <br /> PE SC Received Checkef Amount Ue1e P. Ito Invoice Well IW <br /> Codes Info B Cash Remaded Serivce uastif <br /> wetn+uw oERLaT <br />