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r'l-411111' <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />reyle-MW-UNUAULt rtKMI I %.ALL (LU71874-f OJr FOR INSPEG710N5 thYIKtJ 7 TEAR FROM DATE ISSUED <br />_. �/1INti _._—___.... _9 _ <br />JOB ADDRESS (�Z-&0Z v l O 5eA^ • � ` "' — CITYZP CA— `� <br />CROSS STREET C1`L"a S APN • � + f�1 f - PARCEL SIZE3D ISLAND USE APPLICATION <br />OWNER NAME &ABVY, ty(tLn �. `�✓`R� IAt� ONE �T`L ('�•J�V�l���1 <br />S�TATE/ZPOWNER ADDRESS yI <br />CONTRACTOR PHONC1 <br />. ma((:060 <br />tz t) <br />?' G' 96-7CZ>CI7Y/STATF/ZlPQLP—V�L"Lz"CACACONTRACTOR ADDRES% <br />SUBCONTRACTOR \ �-/ <br />)Arm PHONF <br />SUBCONTRACTOR ADDRESS �l �3 !,/ _ CIT�Y//S�TAA}TF/l�L/IP�_ (,� ?.��1� �/ <br />LICENSE jQ-57 C-61 D-09 ��++ ��Otther NUMBER ZDV ! =, ERPIRATION DATE (�.i. 01 n <br />GEOGRAPHICAL INFORMATION: Coordinates X'01" AA^4Z— Y T.—Inln Ronna Cereinn <br />INTENDED U5E Uornest¢YF'nVals ImgahoNAgncultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different ham Owror er Ys em ame °n a eme ar ne —more, <br />TYPE OF WORK New Well Replacement Well Well AlteratiorVModificalionther '}" 5 r- I/J�k UW <br />Monitoring Well(s) # of wells Soil Boring(s)°I b0°� Geotechnical # °t <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary /"Aluger Cable Tool Push Point Other <br />Proposed Well Depth 3n Excavation �" in dameter Open Bottom Gravel Pack/Gravel Size &:& in Piameter <br />Conductor Casing in diameter / Conductor Cas ng Depth R .� <br />Wall Casing Diameter � in ThicknesslGauge/ASTM Sched y„ Steel lastic Stainless Steel Other <br />Grout Seal Depth_ ft 5A..1 Cement (941b bag310 gat water) Sand Cemem sack mix F7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped ree Fall Other Retardant I Accelerator (name) <br />PEDESTAL Installed By WrAer Pump Contractor Other <br />ConcratepWastal Dimensions Width ft Length R Thick in Christy Bos Wilove Pips <br />PUMP Submers ble Turbine Other HP Pump Set It 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 />MINIMUM 2 VANCE NOT REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-769^7 <br />SIGNED _ TITLE DATE �ust <br />�1 c• I <br />PA TMENT U E ONLY r,q"�7(��,����❑} <br />App,icalion Accepted By Date �/ Area i Y' l `mployee ID# <br />Grout Inspection By Date SPECIAL WBII Permit <br />Pump Inspection By ` Date WAIVER Received <br />Soil Boring Inspection By ax` m- Date Z / Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Date Pumly Invoice K Well IDK <br />Codes Info B Cash Remitted Service Re uest <br />/I� <br />EH O 4I-06 VJ[{L /PUMP PERMIT <br />Encu <br />6$d`l3� <br />Z <br />