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1 <br /> !', WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTYENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46&3420 <br /> MON-REFUNDABLE PERMIT CALL 209 953-769 FOR INSPECTKM EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4,-1 (v S- W c"`P yr c�� PSC', G �, ,z L- <br /> '!Joe AooREss crrr g <br /> Caoss STREET • • PARCH St>B �LAND UtF,APVUCATION# m <br /> OWNER NAMe '"1 C4 <br /> � Q 'I pNIr <br /> j� <br /> OWNER ADORE33 (. ✓ QTY/$TA 1- <br /> u en sz' <br /> CONTRACTORI-V ITTI _ t <br /> l S <br /> CONTRACTOR AOOREsa (-`I{yJ�A LI <br /> SUBCONTRACTOR �� PHONE �Vr <br /> SUBCONTRACTOR ADDRE nn�:i IIj/lSTATEIZP (,. <br /> LICENSE C-57 C-61 D-09 Other L.) NUN I �t� 1 EM4RATION DATE `L <br /> GEOGRAPHICAL INF T10N: Coordinates X - Y <br /> Township_ Range Section <br /> .INTENDED Use omestic/Private IrrigatioNAgriattWral Industrial Water Quality Morrbring Sola Sampfing/Characteriza60n <br /> Public Water Sy-stern. <br /> If diem it from owner aer me U0rW NarnS Of <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #Of wells Soil Boring(s) a w°orW'or Geotechnical °°bo rigs <br /> w <br /> um Cut-Of-Service Well Renewal Crnsy0onrettlon Repair <br /> ce /P1 <br /> R eat Pump Repair Raise Well Casin <br /> J:'FiL�.GFIa fitin:T10N <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Wap Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size In diameter' <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidaness/GatlgeJASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb baq�5-10 gal wafer) Sand Cement sack mbd7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PeoEs'ru metalled By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length R Thick in Christy Box a Pipe <br /> �PUMp ' Submerside Turbine Other HP - - Pump Set ft Standing Water Level _ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VATH SAN <br /> JOAQUIN ORDINANCES STATE LAWS, AND RULES AN REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CU AND CTIVE VdTH CALIFORNIA7EQ <br /> ORS STATE LICENSE BOARD AND THAT I AM IN COpIPIJ/WCE WITH ALL 9 <br /> Rlt ENSATION LAW _MAN TUI D FOR II_NSP/ECTION/S�-t PLEASE CALL(209) -7697 <br /> SIGNED T /�'Y V/iI�.(�// DATE 1� `iS 1-7 <br /> —i <br /> ly <br /> ESV x <br /> f;lt <br /> .UfN E ARTMENT E NLY I��SF ,7�LT� <br /> AL <br /> .. ;NMEtfTI"1�-�rr <br /> PARAII 81tion Accepted B Date_��� Area<<-{-L—� E'npl°y°°ID# 7UI'L•A'W 1/"S R~rC`o <br /> Gran Inspection By Date Z. SPECIAL Well Permit <br /> Pump inspection By <br /> Soil Boring Inspection By Date pled Well Depth R <br /> COMMENTS (- ! <br /> PE SC Received Amount Pemlitl <br /> C Into g Remitted Data Service # Invoice 9 Wee IW <br /> � <br /> EHO•1106 <br /> ,.30 12 WELL/PUMP PERMIT <br />