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<br /> WELL/PLIMP PERMIT
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<br /> ;AN JOAOUIN;CO urI7 ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420
<br /> 1 NOWREFUNDABLE,PERMIT. CALL`.(209)953=7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED
<br /> JOD A — CTYZIP li.1 _<<iiI :1,` =� D \
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<br /> L��rf}l i�•,i 1 I-Ir' 'APN 1P..ARCEL S¢/�u,r LANOUSE APPLICATIONkCROSSSTREET
<br /> OWNER�NAME t � Lr
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<br /> PHONE
<br /> .. •! ALJ�e�=�l� r;K+��1 � (�3
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<br /> OWNER ADDRESS /1�� •I r...: ..�f ��f r:r' _ CITY/STATE/ZIP /1 -,-�r ,y
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<br /> CONTRACTOR I�1'+r 1• f If r 1)T r�l I1, ) I N{. - PH614E /r�L T/ -
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<br /> CONTRACTOII R"ADDRESS C '�.(Lr F•�� !�'F CITY/STATElZIP f 1't u1 S J (,1 r -!5,eJ
<br /> SUBCONTRACTOR 'PHONE
<br /> SUBCONTRACTOR'ADDnESS +/CITY/STATElZIP 77
<br /> LICENSE ),C-57 I7 C•61 :] D 09. :'. D OthBr'- NURtBER fr.f F�C• EXPIRATION DATE �'•.JG �� v
<br /> GEOGRAPHICAL INFORMATION: 'Coordinates XY. 'TownsFitp.." 'Range Section
<br /> INTENDED USE DjDomostic/Prh'alo'`,S�Irrlg lonlAgnculluial 0 7nduStrial- O Water,Quallty Monitoring".- elf Sampling.'Characteilzgtion
<br /> `• OI PublicWater System
<br /> • .1!diNarenl from Ovmer r(, afar yalon, ame - Oo Iact Name oor hftono Number
<br /> TYPE,OF WORK `�(Ne%4 Well L'Replacamenf Well 0 Well AIw,atleNModlllcalicn ^Other
<br /> ►of bcdngs C d,,gs
<br /> ,.0 Monitoring WIell(s) . #of wells 0 Soll.Bor'rg(s)- 0 Geolechnicat
<br /> 0 Out-I ServlFe Well 0 Out•Of-$enlce Well Renewal Cross-Cornechon Repair
<br /> .D New Pum 0 Pump Replacement 0 Pumn Repair 0 Raise V nll Casinq `yU,
<br /> WELL Co sinucTION -
<br /> Drltling Method),k,Mud Rotary 0 Air Rotory 0 Auger. 0 Callo Tcol Push Point 0, Other i
<br /> Proposed Well Depth ':0(5 . It Excavation '?0 _In d!ameter 7 Open Bottom r<jGravel Pack/Gravel Size in diameter
<br /> 0 Conductor Casing. In diameter / Conductor CSsing.Depih
<br /> Well Casing Dlamelbrj_Z1t�Thlckneas/Gauge/ASTM Sched D Steel O.Plastic IJ Stainless Stool „0 Other
<br /> Grout Seal Ddpth , + _ft 0 Neat Cement(94 Ib bag!5-10 gal water) (•Sand Cem6nt f!- `sack mix7 gal water
<br /> 0 Bentonite(20%solidi)' .0'Other
<br /> Grout Plkemon Mðod rlEumped D Froefall 0 Other 0 Retardant/AccelorIajoi(name)
<br /> PEDESTAL. Installed By .O Driller ��;�'ump Cohtractor !iJ Other.' _
<br /> E�ConcretePedestal„Dimehslons..Width. r it Lengtfi. It Thick;• • in.._ O'Christy Box O'Stove,Pipe
<br /> uMP' D Submorsible'I Turbine O,her HP Pump Set. tl Standing Water Level if .
<br /> VVV LHEREBY CERTIFY THAT I HAVE'PREP ARED'THIS.APPLICATION AND THAT,THE WORK WILLBE DONE IN,ACCORDANCE WITH SAN
<br /> JOAOUIN'COUNTY ORDINANCES, STATE'LAWS, AND`RULES AND REGULATIONS.. I ALSO,.CERTIFY THAT.MY REOUIRED,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 /> MINIMUM 24 HOUR-ADVANGE NOTICE'REQUIRED FOR,INSPECTIONS-:PLEASE CALL(209)953-7697
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<br /> SIGNED TITLE -�� :DATE—
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<br /> IL
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<br /> i D,EPA�tt7 1ENT USE ONLY
<br /> Date Area T�lr F/ Employro,ID# 7 L1rJc)'pial
<br /> Auplicatlon Accepted By _L t L--
<br /> Grout Inspoction By Date 11 SPECIAC'Well Permit. 1l
<br /> �l Pump InspectlonBy
<br /> Date WAIVER Receive
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<br /> Soil'Boring Inspection By Dale.. Consir,ueted Well.Depth_ it
<br /> I COMMENTS' -
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<br /> PE' SC Received Check#/ Amount Permit/ Involce# Well ID#
<br /> C Date
<br /> Codes` Info B Cash Remitted Service Re uestiff.
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