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WELLIPUMP PERMIT <br /> SAN JaAwN CcAmw ENVIRONmemTAL HEALTH MPARwENT 900 EAST MM STREET-STOcKTON CA 96202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(209}_953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos AmwBs316LO <br /> T/ �Z /�y� CITaR {� p <br /> CROSS STREET rT/r/p� / / ACL APN z./✓ Ifo- PARf�S��V t.AN0U8EyAPPLICAnaN# <br /> OWNER NAME VA-r OACJ7� PHONE Loo• 835- (l7I <br /> OWNER ADDRESS �A/YID (n-dSTATFMP ._ <br /> CONTRACTOR PHONE 1 <br /> CoNTRAcToR AooREss ,- CRYISTATFJZIP f <br /> SuBcoNTRACroR PHONE <br /> SUBCONTRACTOR ADoREaa CITYISTATE/ZIP _ <br /> LICENSE 1 C-57 ❑C-61 U D-M 7 O@W NumWR EXPIRATION DATE <br /> GEoaRAmiCALINPORMATION: C00fdlnate3X Y Township_ Range Section, <br /> INTENDED USE pCOorneshcANwate L IrrigatioNAgrlaAtixal D Industrial ❑Water Quality Monitoring 7 Soil SamVWgIGharedertratlon <br /> D Public Water n ar <br /> If ddarea tram owner. nrrN— Uorma <br /> Phone <br /> TYPE OF WORK I I New Will i Replecament Wet i I Well AterationNodificirtion Other <br /> ❑Monitoring Wets) t of wells Sod Bdring(S) - N of borings 7 Geotechnical N 0f bu+tngs Q <br /> U Out-Of-SeMce Well C Ord-OFSeMce We[Renewal C Cross-Comedion Repair. �^^y <br /> W New Pump Pump Reptamment- _❑Pump Repar _ 7 Raise Well Casing \� <br /> Well CONSTRUCTION - <br /> .. - - - Drilling Method tl Mud Rotary =Ac Rotary u Auger 7 Cable Toot i I Push Point ❑ Other ,• ,t <br /> Proposed Wen Depth ft Elrcavation in diameter -..I Open Bottom ❑Gmwei Pdck/Gmvel Size in diameter <br /> C Conductor Casing in dlarneter / Conductor Casing Depth ft <br /> Well Casing IAarneter_in ThidmesslGsugelASTM Sched j Steel ❑Plastic i I Steinieso Steel U Otter <br /> Grout Seal Dep9E R C Neat Carnent(.94)b bOW5-10 gal water) ❑Sand Cement sack rrx17 gal water <br /> U Semonite(20%solids) 7 Other <br /> Grout Ptacement Method U Pumped I. Free Fat L Other U Retardant/AacelerBtor(name) t <br /> PEES Installed By ❑Driller Pump Contractor - Other <br /> D Concrato Pedesta)Dltrteaskm&Width ft Length ft Thidr in C Christy Box I I Stove Pipe <br /> PUMP XSubrnersi6ta-Turbine I t Other_ FLP r�2- Pump SW__E2- it StvatW Water Level 4 a R <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE <br /> �/REQUIRED c�.1��C'tlK�a�./'FOR INSPECTIONS <br /> TZnrDAre 1012-3 O°/ <br /> - Ti II <br /> i <br /> T <br /> _ D <br /> DEPARTMENT US ON Y <br /> Application Accepted BY ... — d Area Employee IDA�`-S�� <br /> Grout Inspection By SPEcIALWall Permit <br /> Pimp Inspeerion BY ace WAIVER Received <br /> SW Boring 1n BY Date ConsMKtod WE41 Depth it <br /> COMM S <br /> Reeet"d Amount M>rdu0 well ID* <br /> Codes Info Rerrrittod Date Sertrke RN vest i <br /> p 3q b Ilk @ + 3 0 - ul oda <br /> E113 43-a0 M wF1 L NLIMP PER-AR <br /> W04108 <br />