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WELLTUM'P PERMIT <br /> SAN JOAOUiN COUNTY ENWROHMVNTAL HFALTN DEPARTMENT 600 SASS MAIN STREET-STacKTON CA 952!72 -(249)46$•3420 <br /> KION-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPEC71ONS EXPIRES 9 YEAR FROM-DATE;ISSUED � <br /> CITYIYJP <br /> Lop .9 5 <br /> JOB ADDRESS <br /> CROSSS_, APN PARCEL SIZE LMD USE APPLICATION <br /> 1I 1I 3n> <br /> # m <br /> ] <br /> OWNER NAME L b� Loo pNONfti+-C.F� f, 4 <br /> CITYISTATE/ZIp <br /> OWNER ADDRESS 1`4 <br /> PHONECONTRACTOR <br /> CONTRACTOR ADDRESS 341ti W. �It:it IF'7L,L��._ CITYISTATEMP�,G3rtcr8 ra �rA1.1 9s.�� <br /> I LL61 L) j2rrjC�' iL. 1 _ PHONE?OfPis– �� 0 <br /> SUBCONTRACTOR <br /> p <br /> SUBCONTRACTOR t• <br /> ADDRESS 4. DM CITYISTATFJZIP <br /> LICENSE G97 G G81 0 D-os n Other NUMBER '90027 EXPIRATION DATE (kTeSfR 20�� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Townships„ Range Section <br /> INTENDED USE 0 DOMBSEC/Private 0 irrigation/Agricultural G Industria! 0 Water Quality Monitoring XSoil SamplinglCharacteAZatlon <br /> wIfdbefrr r m src,e amor I— <br /> — <br /> If ftwd from r <br /> TYPE OF VYORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other v of buringa <br /> ❑Monitoring Well(s) #of wells )(Sol, <br /> B0 <br /> 6 <br /> ng{s}_o3tt of borings Q Geotechnical <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 pump Replacement ❑Pump Repair <br /> WELL COMTRUCTION . <br /> Drilling Method 0 Mud Rotary r n Air Rotary XAuger R Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth 2 0 _it Excavation—In diameter ©Open Bottom D Gravel PacWGravel Size in diameter <br /> 0 Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter___in ThicknesslGaugeIASTM Schell ❑Steel r Plastic u Stainless Steel 0 Other <br /> Grout Seal Depth ZQr ft 0 Neat Cement{941b bag/5 fD gal water) C Sand Cement sarkmiud7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement ethod D Pumped X(FMR F211 Cl Other 0 Retardant I Accelerator(name) <br /> PEDESTAL Installed By U Driller 0 Pump Contractor 13 _Other <br /> D ConeTete Pedestal Dimensions:Width ft Length It Thick in 0 Christy Box 0 Stove Pipe <br /> PrIMp 0 SupmerslbleG Turbine 0 Other HP Pump Set ft Standing Wafer Level 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 AND REGULATIONS. I ALSO CERTIFY 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 /> M PH t1M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS l�/a <br /> C_:� TIT. i �f / fl�Z DATE <br /> SI8NE0 <br /> O � Y <br /> g <br /> re r `� <br /> Z z <br /> lu � <br /> a <br /> t <br /> 0 <br /> ® O r <br /> !� <br /> 01 <br /> LO1�MI CIPA tP7 m <br /> CI F}RI <br /> �t/r f1j� <br /> LAKE'ra•ARIr 3 6 Ir -f <br /> 0 <br /> �B � <br /> U <br /> TURINER <br /> A T N <br /> D SSPA TMENT U E NL <br /> Application Accep 1 , Date Area Employee IDIF <br /> Grout inspection By Date ❑ SPECIAL Well Permit <br /> a�{ <br /> Ins iars By Date ❑ WAIVER ReceivedPum <br /> P P� <br /> Date Constructed Well Depth ft <br /> Soil Boring Inspection By <br /> COMMENTS { ' N <br /> pE Sc Received Amount Porrrdtl Invoice# Well ID# <br /> Codes Into B Cash Remitted <br /> Date Service Reguest# <br /> 3IN-7-7$" o SRt7b535�3- <br /> WELL!PUMP PERMIT <br /> FHD 431M <br />