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/1, -z <br /> I' <br /> Yx Al-11 S ("-\ I I.I6-16 CJS^ <br /> - �� WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IBM EAST HA TON AVEHUE-STOCKTON CA 95205-(209)6611 <br /> NON-REFUNDABLE PERMIT CALL 20099)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDflEa$ �� (�� D <br /> CnZP�' R <br /> yam9 3 <br /> Joe AWTREET al/N-L. APN�/O-7- PARCEi S� LAND USli^AyYP��PL��ICATIOON 0 �J <br /> OWNER NAME PHON, X)(I—r I— II/JlD " <br /> OWNER AO0REss r CRYISTATEMP czs I/ 4 <br /> CONnCTOR 1 PHOxE <br /> U1 <br /> COMRACTOR ADDRESS CRYISTATEMP o7I <br /> SUBcoMRACTOR PHONE <br /> SUBCONTRACTOR ADORESs CRYISTATEZP <br /> LICENSE GSI CSt D-09 Other NUMBER ItAinom DATE r <br /> DEDDRAPK LIxFO nON: COordlruhsX Y ToWDSN _ <br /> p_ Range_ Seclfon <br /> INTENDEDUSE D0mftAbQPrlvate Ixipation(Agrloubuill Industrial WaterOusliy Monitoring Soil Sampling/Characterl"bon <br /> Pudic Water System <br /> ItaMam[ecm Omer. Waist Graimi Dime artew <br /> TYPEOFWORN Y-14"well Replacement Well Wag PReradoNModification Other <br /> Monitoring Well(A aor walls Soil Bonw(s) eaean"ae Geotechnical •OI OOR"as <br /> OutCfSaMce Well OutOfSeMcs Well Renevwl Cross-Connection Repair <br /> III..Pump Pump Replacement Pump Repair Raise Well Casing <br /> LC NST U <br /> Drilling Method Mud69Mry_ Air Rotary Aug�er ��(,C�p bb Tool Push Point Other <br /> Proposed Well *Depth. B Exmvetion _ In diameter Open Bothem XGrevel PeddGraysl Siza in diameter <br /> Conduct Gsinp_In diameter I Conductor Casing Depth R <br /> Well Casing Diameter In Thickness1Geuge1ASTM Schad 'ki!xD Sisal Plastic Stall sSta Oder <br /> Grout Seal Depth -IT <br /> Neat Cement(94 It,bays TO gal water ysand CA sack mbrl7 gal water <br /> Bemoao0ds) Diner <br /> OroW Placement MethodnNa Pumped Free Fall Other Retardant r Accelerator(name) <br /> EUNZ& Installed By Driller Pump Contractor Other <br /> Concrete Patlastal Dimenabns:Wtlth R Len91h R Thick In Chnary Sox Stove Pipe <br /> PUMP Submersible In Other HP Pump Sat R Slanding Water Level R <br /> I HEREBY CERTIFY THAT I LfAVE PRO <br /> R ARED THIS APPLIC N AND THAT THE WORM WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOVIN COUNTY ORDINA ES, STA LAWS, AND R S A REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE W E IFORNIA CON CTORS TATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C P O <br /> 24 €'N�TIC EQUIR D F I E N E CALL(2091 i 76 <br /> SIGN V TITLE DAIS lCLe <br /> Err <br /> IVSD <br /> �� 2016 <br /> IN CpI1NTy <br /> i A MENTAL <br /> EP RTMENT SE NLY ��a����//ff//�1 �/��i/ <br /> Application Aceepled Gle ( Area�IT Employee IDa_��lr[ 0 <br /> Grout Inspection Dar SPECIAL Well Permit <br /> Pump Inspection By Date _ WIUVER Received <br /> Soil BodingInnspection By Date Cone4uctad Wall Depth R <br /> COMMENTS 1n P,tA`F <br /> PESC Received C Amount Dar PWMW Invoice It WON IDI{ <br /> Codes Info B ah Remitted SerW.R / <br /> l G II P1Ito 74,ZQ> <br /> pO 3 <br /> EHDUIIB WELL RUMP PERMIT <br /> x(.bl] <br />