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r <br /> i <br /> WELLIPUMP PERMIT <br /> SAN JoAwN COUNTY ENMONMENTAL HEMTN DEPARTMENT 1868 EAST HAMILTON AvENue-STOCKTON CA 96206-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ALL{409 053-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoeAooREss �'✓� Sr -�►^t( - CITvffw i <br /> CROSS STREET �7 tS'�I:�11 - LWI) APN 'J oO MCELSIZF'7 �LANDUSEAPPLICAmN/ .0 <br /> 0I NAME PNON[ <br /> OWNER ADDRESS - I?L:.Il l c. `>! CITYISTATE12i -�'i7'� "1��1.1r t SGT .:�-- � <br /> CONTRACTOR 1PHaN ? r17'(p t.C y�16. - •.^�, <br /> may} yv�s�r tr ■ <br /> CONTRACTOR AooREsa jLe i -j {t't/'.�;•�.�'.� !-('• CITY/BTATE/Zw <br /> SUBCONTRACTOR Ji i 0) D"t I,1 tl;�=•) rNDEae 2 U`i `/1^`7- J 7C(: <br /> SUBCONTRACTOR ADDRESS T <br /> 4 � �.✓�Lt.l '7;� CI771STATE/ZIT <br /> LICENSE 0 C-87 D C-61 ]D-09 =Other ���_ NUMBER EIIPIMTtN4 DATE <br /> GEOGRAPMCALIMFORNA71ON: Coordinates)( Y Township_ Range_ Section U ^ ' ■ <br /> t l + ' ■ <br /> IN7ENnED UsE Dorrlestleftvale -1 krlgaIIoNADrlcu9lxai liindustrial D Waler Quality Monitoring D Soil Sampling/Characterization fir- '�� <br /> Public Water System O- � �► i <br /> M ml6lera Sem Uwgr. a y ee nw c •—or r r f� r-4- <br /> on <br /> TYPE OFWaRK 'New Well =Replacement Well 0 Well AlleralioNUodificalion O <br /> _ <br /> Monitoring Well(s)_ a of wells U SOII Bodng(s) a e16°nro6 U Geokchnlcal 9f <br /> r ee�° O tQ 4sasueaM <br /> =Oul•OfSenAce Well U OWOf-SeMce Wax Renewal O CToes Coltreactlon Repair n <br /> _ -__New Pump—__ Pump Replacement n Pump Repair n Raise Well Casing oeasasael <br /> WELL CONSTRUCTION —, r�'1 <br /> Drilling Method -Mud Rotary SL Air Rotary ,'Auger n Cade Tool n Push Point r Other C3 CD <br /> Proposed Well Depth X75 It Excavelion YI diameter ]Open Bottom O Gravel PacklGrawl Size In diameter CO CD <br /> _Conductor Casing in diameter I Conductor Casing Depth R c -X - <br /> Well Casing Diameter_ _In Thlckness/Gauge/ASTM Schad 7 Steel O Plastic O Stainless Steel n Other CL-P. o:f' <br /> Grout Seal Depth S" R u Neal Cement(94 M bW-5-10 gal water) U Sand Cement Sack mix!/Dal water O� � <br /> CCB ionlle(20%solids) G Other „3 e <br /> Grout Placement Method U Pumped U Frea FB11 D Other 3 Relardanl/A'eleralor(name) <br /> PEDESTAL InstalledBy t_Ddfer u Pump Contractor _ Olhar <br /> -Concrete Pedestal'Dimension*:Width_R Length (t Thick _inhrlsty Box l Stove Pipe w' <br /> PUMP -Submersible[Turbine D Other HP Pump Set K Standing Water Level R -a .•-r �q <br /> I HEREBYCERTIFY T I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUDIT9 OR NANCES,-STM LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE Is <br /> Cl1TtRENY A ACTIVE ITH THE CALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS PENSATICN LAWS. <br /> M 2 'HOUR <br /> ADVANCE NOTICE REQUIRED FqR INSCPECTIO►1 LEASE CALL(209)8t3-/76 7 <br /> 6tONE i' )1 t� TI7LE 1��as)� ] � DATE t l l.1 7 <br /> PERMIT <br /> v�D <br /> Permit may h : A 6 �p15 <br /> UNIN <br /> r.0 beim C0 o CIC <br /> f NA <br /> by E:nv'Sonm,r� <br /> Hn <br /> DEPARTMENT US& ONLY <br /> Application Accepted By Date ( Area D Employee IDIF <br /> GFout Inspection By Date Q SPECIAL Well Permit <br /> Pump Inspection By— Date D WAIVER Received <br /> SON Dorfng Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Received CII Amount Dab rmlu Invoice/ Well ID# <br /> Codes Info Remitted Eerylca_eq oata <br /> END 47-06 WELL fUNP PERMIT <br /> 411 <br />