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WELUPUMP PERMIT <br /> SAN JDAou1N COUNTY ENVIKowmiwTAL HmTH DEPARTMENT 198E EAST HAZELTON AVENUE-STOCKTON CA 95205{232(209)468,120 <br /> NONREFUNDABLE PERMIT WWW.Bjcoy.Orgfehd EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADORES! 0 M A N C N EZ LA N G Cmmo 5-ro C'K.TO N Y$Zo_7 "1 <br /> CROSS STREET 1 yo L-I DA Y DQ.. APN J 1 01 I9Pk► � <br /> ��I c ARC[L SIZE . _LArIO USE <br /> /A'APPLICATION JR p <br /> OWNER NAME C I r r �0/ f S TO�i K-7-0� P110NE S�-)q) 1 3 7— 0 Zit Z, ,i6ts <br /> OWNER ADoRESS _ I /`l If L D0 XA,00 S T CRYISTAWZIP :5"C.Ie—7-0A CA 9s' <br /> CONTRACTOR 7-'g') C U U"1 TY jD(L 1 L L.) 1J(r /A!C PP..E g 271- <br /> 00� <br /> S� <br /> CONTRACTOR AOORlse 6 3 1 G 04 p 110 A s T" Cm/STAT. 510'V D/ZGv. 1f,4 'FV7_6 <br /> SUBCONrRACTOR/CONSULTANT P P 1�V A^',* CO&4-LVS <br /> 10 <br /> AJ S P£C/k LTUf"1e /O�S�jj/.�Z3 Z <br /> SVBCONTRAC70RICONSUITAM ADDI1Eaa 83 7 I �V i's1 r EIfe! 7J O4. CCffyMTATE/ZU <br /> LI /r'�LC.�IIcSvI LC.E �Jo Z�� <br /> CENSE wte`57 -G61 8119 ,otter NUMBER 5"737 EXPPATK)m DATE / 30 Z.0 2z <br /> B.&LWO PART': ❑OWNER C CONTRACTOR .1 SUBCONTRACTOWCONSULTANT <br /> DOMESTIC WELL SAMPLING:o General MlneraVCof form Bacteria(4391)0 DWfomOCAloropropane(4392)2 Arsenic(4393) <br /> IIRENDED USE DomecDrJPrrvste n krigatloNAgrlcufhffal Industrial -i Water Oua Mo <br /> „Y nrtorkp I Sal Sampnng/Cheracter¢atlon <br /> C PuDBC taster System <br /> N dsrereM floor Omer iter System me mm r <br /> TYPE OF WORK INOW Well iReplacement Wen , We0Afteration/ModFReatfon irOOwr 1C G.T�0`N <br /> Monitoring Wen(s) )l at Wells r-Son Boring(s) adDoiLiq' n Geotechnical ro1 o0rtn� <br /> _t Out-OfService Wen '_ Out-Of-Service Well Renewal I Crow-Connection Repair <br /> C Now Pum 0 Pump Re cement 0 Pump Repair C Raise Well Cuing <br /> WELL CONsiwucTtoN�� <br /> Drilling Method 3'Mud Rotary LJ Alf Rotary ❑Auger C Cable Tool 0 Push Point C Other <br /> Proposed Wall Depth Ks R Excavation 12- In diameter C Open Bottom i Gravel Pack/Gravel Size In diameter <br /> I Conductor Casing in diameter l Conductor Casing Depth R <br /> Well Casing Dlamete- —In Thlckness/Geuge/ASTM Scheel C Steal [``Plastic 0 StalNesS Steel C Other <br /> Grout Seal Depth 2:6 n Neat Cement(94/b bep�10 gel weler) Avid Cemenl_ 4__sack frdxf7 gal Water <br /> -1 Bentonite((2/20%solids) Other <br /> Grout Placement Method --Pumped I Fres Fan -Other 7 Retardant/Accelerator(name) <br /> Es installed By C Dritler C Pump Contractor Other <br /> 7 Conoete Pedeetai L Dlnenelons:Width_B Length fi ThIck In C Christy Box �:Stow Plpe I <br /> IPU rte► =Submersibk0 Turbins ❑Other HP Pump Set R Slend'ng Water LevN A <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTNE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> M NlMlibl 48 HO ANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)953- E9 <br /> SIGNED - --C� ..r - TITLE OPE/.0r;u N f ^"Ag �o �7 2W I, <br /> FEN r <br /> QED <br /> 2021 <br /> UI <br /> P4 L <br /> T MENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �?Aj L' Date Ams D 51--6 k l„r7 <br /> Employee IOC AJA <br /> Grout Mspectbn By t J 12 Dste G' Z�� ❑ SPECIAL W!U Permit <br /> Pump Inspection By Data 0 WAVER ROC*tVod <br /> Soll Borkp Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PEBe <br /> Codes Into e.l Cash Reminod s Service ueat f Invoke 9 Well DII <br /> d- 14 3d_" <br /> 000-0e d7+mn WELL PUMP PERNIT <br /> �x 1z71/ 761 <br />