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` IA/` ?j <br /> WELUPUMPPERMIT <br /> SAN JOAOIAN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1238 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> C2 m <br /> J08ADDRESS til 1. CRY2rP �'yy��))rr,,�� b��V//�)D ll <br /> CROSS STREET -tjj' ti• { APN-2D`j- L 10()-U� PARCEL S1ZSi LLLLAND USE APPLICATION it Om <br /> GNNER NAIJE �C(II1 t� PHONEE n <br /> OWNER ADDRESS/^�T1�F'D/�i.,t`� +��� DI t CITY/STATE2w.1.1 Y1`1 �^, (�� <br /> CONTRACTOR I�C O.(l./{� +y-y�c�'(,>S" 2 �/�J�-( Drt l l I•h�- 1� ,PHONE 2211--'I�Leg,3,S- <br /> CONTRACTOR ADDRESS I Y}� }V �'1 CfTY/STATT`/ZIP }yl Qlitli� T`'' ���� <br /> SUECONTRACT A I V / (AAT`` �Iyy PHONE ISI I V� <br /> SUBCONTRACTOR ADDRESS l�'r, CITY/STATE/ZIP <br /> LICENSE r <br /> 57 C-61 D-09 Other NuuBER Yf/-i(..� w E%PoRATn0N DATE <br /> GEOGRAPHICAL INFORMATgH: Coordinates Y Toarnshlp_ Range_ Sectlon� <br /> INTENDED USE XDomestWPrivaie Inigatioa/Agriailtural Industrial Water Qu2ity Monitoring Soil Sampling/Charaderuzlion <br /> Public Water System <br /> tl dr—t Rom Oxrar: C-tSrA NBrr4 Of PhDna u <br /> TYPE OF WORK XNew Well )(Replaoemom Well Well Attema on/Modiflcation Other <br /> Monitoring Wells) #dwells Soil BOdng(s) �o1 bo0e Gedechnical 0.1 b°nnpt <br /> Out-Of-Service Well Out-OfServke Well Renev sl Cmss-Corneclien Repair <br /> New Pump Pump Replacement Pump Repair Raise Krell Cash <br /> WELL CoNsTrrucnoN <br /> Drilling Method 04'Mud Rotary AIT Rotary Auger Cable Tool Push Point Other <br /> Proposed WEII Depth �9 C/� , E%Cava110n '.yl- in diameter Open Bolton Gravel Pack/Gravel Size In diemeler <br /> Conductor Casi np in diameter f Condlldor Casing Depth ft <br /> Welt Cuing Diameter E in Thickness/Gauge/ASTM Srhed 5 Steel )CPiastic Stainless Steel Other <br /> Grout Seal Neat Cement(94/b bag 10g water) Sand Cementrt sack m/x/7 gal w <br /> `/ tantte f20%solid Other <br /> Grout Placemen ethod X Pumped Free Fall other Retardant/Accelerator(name) <br /> PEQESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Wtdlh_ft Length ftThick in Christy Box Stove Pipe <br /> PUTAP Submersible Turbine Other HP Pump Set ft Standing Winer tcvel tl <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. t 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 COMPENSAIIOWIAWS. <br /> MINIMUM OTICE REQUIRED FOR INSPEC[IONNrS-PLEASE CALL(209)953/-7697 <br /> SIGNED TITLE 1���� �Is)l DATE 1 `/7 <br /> 0 - 10 <br /> So!L T <br /> g S <br /> r- <br /> �� S�GW N o z <br /> Cc + ._ Z <br /> S� C w LU <br /> �.. W J z <br /> a W ? cla_ <br /> s <br /> -7r <br /> ------------ <br /> v << <br /> � SIL EFA 7MENT SE ONL <br /> ��o <br /> Application Accepted r l Arse _ Empl. ID1t /,J .1 <br /> t ✓ <br /> G 7 SPECIAL II Permit^�1 Grout Inspection By D�- <br /> 1 V / Pump Inspection By Data J WAIVER REGGIVCd <br /> Soil Boring lospxtio n By Date - onstructe Well Depth _it <br /> L ` COMMENTS <br /> SooC((� PE SC At— <br /> Receved Checkt/ Amount PerTr'U Invoice well Do <br /> Codas Info Cash Fetes Data Service to <br /> z _I 0 �l ll �ROd�IQ� <br /> &A <br />