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WELLJ4>IMP01914MIT 803230-7q <br /> SAN JOAOUIN CouNTY ENinNommEKTAL HEALTH DEPARnmarr 111M Eks'FHAZELTON AVENUE-STOCKTON CAV5206-(209)4904W <br /> •NON-AEFUNDABLE PER IT / GALL 209,�,+34,S97 FOBINSPECYI NS'. - XPIR S}YEAR FROWDAIE ISSSED <br /> F�� <br /> eS' (_cLYN�;(�rn-. rid _ CmmP S�T.�c—�-- W� '��3�cr 41111.11 SPIN PARCEL SIZED•titf .LANA USE AAAPPPLICAT10N a �Q <br /> - PHONE <br /> [� <br /> .I scmFsrATErzIP +'t'1 rJ c—•-�yf�ti r <br /> CDNrRADTOIi P.1f7. em/hs 0 r/l� PNdYI)E•�-••r �y ,S' p, <br /> CONTRACTOR ADDRESS I.060of (I''d CRY/STATERp j)?Ic s4 -4 r <br /> SuacowrRACTOR - - PHONE <br /> SUB CONTRACTOR ADDRESS Cm/STATE/ZIP. <br /> LICENSE C.57 n C-61 00-09 D DDldf I'IUs7BER EXPIRATION DATE7 � <br /> , <br /> GEOGRAPHICAL INFORMATKs9: Coordinate% Y Tdwnship_Ranye_ Section_ <br /> INTENDED USE Dome rrivate C IrrigadorUAgrieultural D Industrial O Water-Oyallty.Wrillonng U Solt Sampling/Characterization <br /> [1 PuW�Ica�aNl%,SCwnereT aisr Nams aerne v r <br /> n� <br /> TYPE OF WORK 0 New Wes 'eplacamen('Well D Well AlleratlbNModllication OOther <br /> O MorKtoring WNI(s) dol wells 0 Soll Boring(s) aol"Mn"" 0 Geotechnlcal sofmmos <br /> I 0 Out-OI-SeMce Well 0 Out-OI-SeNica Well Renewal, 0 Cross-Connectlon Repair <br /> 0 New Pum 0 Pump Replacement 0 Pump Repair D Raise Wall-Casio <br /> WELL CONSTRUCTION - <br /> Drilling Method)Mud pottery (3 Air Rotary 0 Auger U Cable Teel 0 Push Point ❑ Other _ <br /> Proposed Wall Depth h Excavation <br /> A�Q_ fT In diameter O Open Bottom ravel Pack/Gravel Size In diameter I <br /> O,Ponductor Casing In diameter / Conddickir CasingDepth h <br /> Well Ceslnp Dlemeterin ThkKness/Gauge/ASTM Schad.J'', 0 Steel )(Plestic 0 Stainless Steal 0 Other <br /> Grout Seal Depth /QD It n Neat Cement(94 1D baI 100 water) 0 Sand Cement seek ffA*7 gal water <br /> 'cr6enlomte(20%.solids) O Other <br /> Grout Placemen/!Method umpad ❑Free Fall 0 Other O RetardantI Accelerator(name) <br /> PEDESTAL InBlatled By ❑Driller Pump ConDagor O Other _ <br /> n Concrete-Pedestai ODlmenslooa:Width h, Lang- R- ek In 0 Christy Bos D$tbve Plpe <br /> 1 <br /> 1p-P C Submereible0 Turbine Il Other . HP Pump 91' It Standing Water Level it <br /> t HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION A40 4TZJ W W1LL,BE C ff{{�E�9N'ACCCC,ORDANCE-WITH SAN <br /> JO,Q¢UINCpUNTY ORDINANCES,6TATE LAWS,'AND RULES AHb�1Ey TIgNS-'i,A STE1}ktF'aIY�REO771REC)"LICEN9@ 1 <br /> CURRENT AN0 ACTIVE WITH THE CALIFORNIA CbA.TAACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. t <br /> MIWMUM 24 HOUR A�DVAFjICE NOTICE REQUIRED-.FO9R-INSPEOSIONS-PLEASE CALL(.209)953-7697 <br /> SIGHED Vi} 61�1e2.AP'&VL TITLE1'^It�je,� DATEV f.-b- <br /> A <br /> I <br /> t <br /> LI W Aly k9 <br /> WHilm <br /> 41 <br /> IIJEIIIARTWENT,U,SE IONLY <br /> Application Accepted By svlDate f r Area Employee IDe( =I t IVL <br /> Grose Inspectiorl9x gate. � q ,SPEPIAL Well Permit. <br /> Pump Inspection By Date O WAIYER-Recel-ved <br /> Soil Boring lnspecilon By Date Cons4*Isd,WeB Depth N <br /> COMMENTS hi I ja! I*V k <br /> PE SC gapeIV" Check/ Amour. Date - "PermlU Inlrolce P Well IDe <br /> Codes kdo 8 Cash Remitted Service-R Service-Request It <br />