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*HELL/PUMP PERMIT •q <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTONAVENUE-STOCKTON AA`95220051 `209)�68.3d2 y <br /> NON-REFUNDABLE PERMITCALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YE/PK.tJIVgL �n't <br /> gf'/SA/AVV DR— C"17jP ��rK�a/l (a <br /> JOB ADDRESS � bo <br /> 1106OO pec/J �— IN I6 EGD i0D S PARCEL SIZE__LAND USE APPLICATION# N <br /> CROSS STREET Il O/ <br /> S ti a l PHONE 1C 4 J W S <br /> OWNER NAME �J �J �sr� C•� ..�r� <br /> OWNERAUDRESS -10-1/J� effee'So� �r CRY/STATEZP hSAOtrXJ�./ rJ (' <br /> CONTRACTOR coir ie „ fi�rr_'n�J l� PHONE SID bI W� � dd 0 <br /> 2AQcLl CA4301 2LIA CRY/STATEIZIP LL..e. ..�rT �q- �) LS' <br /> CONTRACTOR ADDRESS 3 3 -S$d <br /> /. i I F S�A� PHONE�a�- ) O <br /> SUBCONTRACTOR g♦:ls{ �'I��LL.-1N � 3 <br /> SUBCONTRACTOR ADDRESS �`a P.,,r CRYISTATERIP ✓GZ <br /> LICENSEG57 ❑G61 ❑D-09 G Other <br /> NUMBERS E%PIRATIONDATE SO 261 <br /> Y Township__ RangeSection— <br /> GIOGWHIC <br /> TENDED USEL INFORMATION: CDordlnates X Soil Sam lin /Characterization <br /> INTENDED USE O DomestirlPnva[e G Irdgetlon/Agricultural O Industrial ❑Water QualityMonitoring ❑ P 9 <br /> ❑ <br /> Public WaterSystemnam arae na arae ar um r <br /> r'•ly�iLM 20271�DA� <br /> TmEOF WORK New Well ❑Replacement Well OWell MwrabonfModificationa cor's ilawd.ga <br /> D Monitoring Well(s)__#af wells ❑Sail Bodng(s) <br /> d_ ❑Geolechnial <br /> D Out-Of-service Well 0 Out-Of-Service Well Renewal GCross-Connection Repair <br /> r_t New Pum C Pum Re lacemenl D Pum Repair O Raise Well Casin <br /> WE CONSTRUCTION <br /> Drilling Method XMud RR�ott�a..,,ry,� ❑Air Rotary C Auger G Cable Toot 0 Push Point 0 Other <br /> Proposed Well Depth�ft Excavation In diameter a Open Bo)p , U Gravel{Pa`eW�vel Sizer In diameter <br /> Conductor Casing in diameter I Conductor Casing Depth it IJV 5 i7(f/Q.-4 <br /> U Steal lI Plastic II Stainless Steel L'Other <br /> Well Casing lameter' In ThicknesslGaugeIASTM Schad Send Cement sack mod7,,ggat water <br /> Grout Seal Depih_ —ft Neat Cement(944 Da§/5-10 al wa�tyer) A/,yII'��� <br /> OBentonite(20%solids) XOmer 'PQ ��u')T"��)��� <br /> Graut Placemen!McNotl Pumpetl G Free Fall O Other <br /> G Retardant!Accelerator(name) <br /> pEoesrAL Installed By 0 Driller G Pump Contractor ❑ Other ftThick in ❑.Christy Box 0 Stove Pipe <br /> O Concrete Pedestal ODimensions:Width_ft Length <br /> Pump 1.1 Submersible'I Turbine Uher OtHP Pump Set ft Standing Water 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 /> MINIMU�II 24 HQUR ADVJ CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(269)9fZ-7 97,,/ <br /> //`` L6i ld��i�if'J TmE.�c�✓Sr JJPtI-y+%ID�..A� DAre <br /> SIGHED R.4`� <br /> A <br /> r 1 /SFP 0 FNFa <br /> C <br /> 4 2414 <br /> >�a�F�44� <br /> SPAT <br /> ` .. DEP�A RTM ENT Uf:SnyEnONLY.yy/f•• /�/✓ 1 r/"` Date �lZ ♦ \� AreaObi Of Employee ID#. <br /> Application Accepted By�_ <br /> Grout Inspection By <br /> Dale ❑ SPECIAL Well Pertnit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Inspection By <br /> Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received CheclC# Amount Dale permlU Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re oast# <br /> tit �7aL 1G. L✓ 4.� sQpU7D453 <br /> weRUMP PERMR <br /> FHOa5a6 <br /> 6.� <br /> a13o112 <br />