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` \I WELUPUMP PERMIT <br /> ftNVtR�`%IT <br /> SAN JOAOUN COUNTY ONNE NAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•STOCKTON CA 95105-(109)468-3420 <br /> NON-REFUNDABLE PERMIT j,'`' CALL 209 953-7697FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDREss 1 1 r T��1 1 tr),✓c a s_ � �`r-eL' +'1`(�p Crrv2m �- (� , , �� <br /> CROSS STREET 14 w y '04 V 1 L-A L'r APN �p `� PARCEL S¢E 1 7�C% o <br /> / ! _ LAND USE APPLICAmoN S M <br /> OWNER NAME _ t rYt��� I may` S{ _ PHONE _ <br /> OWNER ADDRESS `}� 1L pL`lJ j,.P C•1•S I 1i�'` rL CRY/STATEIDP L C{� 1 t!C lA ^C��C�,..-t7`T C. <br /> CONTRACTOR V C 1 l.-] ��S�I �, 1 C - PNOIff _h:rin - R(�! /J 1 <br /> CONTRACTOR ADDRESS 1-C' 1s L'r�, C.1STATE21P �1�1 ( A� S 7Y�'7 D <br /> SUBCONTRACTOR PHONE <br /> ' SUBCONTRACTOR ADDRESS CR/y'/j/STAT�E7/ZJP <br /> LICENSE -57 - -61 D-09 _ Ofhef NUMBER I .J!' � E%PIRAnoNDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED UsE =DomesticrPrivate 7JrrigadorvAgricultural =Industrial =Water Quafdy Monitoring Sal Samping/Cheraderization <br /> ' ' Public Water System <br /> U dplic of Tum Owner: WM., a a <br /> TYPE OF WORK )(,New Well --Replacement Well =Well ANeration/Modfication =Other <br /> Monitoring Well(s) *of WeiS L SON BOrifVS) sof bod(CS _Geotechnical If or eodrgs <br /> t r Out-Of-Service Well -Out-Of-Service Wel Renewal -Cross-Connection Repair <br /> ew Puny Pump Replacement Pump Repair L Rase Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)CMud Rotary "Air Rotary Auger Cable Tool - Push Point Other <br /> Proposed Well Depth ?A R Excavatlon_14 in diameter -Open Bottom >(Gravel Pack/Gravel Size-24---in diameter <br /> ' :;ConducW Casing in diameter 1 Conductor Casing Depth fl <br /> Well Casing Diameter In i P ess/Gauge/ASTMSdted ' =Steel >C.Plastic L Stainless Steel Other <br /> Grout Seal Depth�_n _!Neat Cement(94/11 bay/&10 gal water) -A-Sand Cement sack mini!gal water <br /> .;Bentonite(20%solds) j Other <br /> ' Grout Placement Method 4Pumped .:Free Fall L.Other _Retardant/Accelerator(name) <br /> P installed By e _Pump Contractor, Oiler <br /> oncrete Pedestal'Dimenatons:Width ? it LengM it Thick in -.7.Christy Box .-Stove Pipe <br /> P - Submersibie-Turbine 7 Other KP-15— Pump Set n Standing Water Level - n <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMPM <br /> �24 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SCNEO - c_-tl� Cli Z'�+�tr�- Trn>:• V+(� I t DanE ` 14 <br /> c� <br /> ( .. <br /> J <br /> r <br /> f <br /> 1. <br /> DEPARTMENT US ONLY 1�/ % <br /> AppfcabatAcoepEed By' I Dale Area CAI g 9 1 <br /> ErapioyeelDa <br /> Grout irepec6cn 133 441, azza Dale D SPECIAL WON Permit <br /> Pump 1 Dais // /� WAflIER Received .� <br /> Soil 80"inaPe ct-By Dale Comstruclod wet Depth n V� <br /> COMMENTS PE V ,�1 <br /> PWOW <br /> Codes JIMRaceive0 it AnreaA D� Senks a Invoice a <br /> IS <br /> EMO C4e8 'JrEJi fi+JYP F4P.. <br /> 40VI2 r� <br />