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WELL/MW POSIT <br /> -S"JOAQuiAwY ENVIRONMENTAL HFALTH DEPARTMENT 600 EAST MAIN STREET-STocKTON CA 95202 -(2(19)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7607 FUR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> JW ADoREss Z 0 Q N. Wilt <br /> AtA /1 Ire. <br /> 'Ire• C"IZIP .5 lock}01) _ -/��• <br /> GROW STREET APN 1-T "20- l0 PARCELSIZE LANDUWAPPUCATION#_ <br /> OWNER NAME yJ.(.A C-OO)'�y�O7'A} 071/L� [ PHONE L('v,/('ld-las^ '�J-IS) <br /> OWNER ADDRESS Zr�ooy, W/ R9HCa AVC Crrr)STATFMP✓ vKfpN! 64 ` zis- <br /> CONTRACTOR k7G Ary LOM1)YtAr <br /> ' aPHONE(`5'fbo0)) 671wy-- 103( <br /> �3 <br /> CaNmADOREW 389 CITYISTATEIZIP yH1a l C4af <br /> SuaCoATOR Dkkk 5wrovinvii PHONE <br /> SUCONTRCTOR ADDRES /Oar _ <br /> ..,,. <br /> 7-kW if71'(�@t1 --....._ C"IISSTTATERmP 6)?Chlt AS . 6A`__ Yi0z <br /> LICENSE CS7 C-61 0-09 �2 Ome�Cr-+s ��..p y,� NIUM��'EQ�JR Eby`�/(�/j�If EXPIRATION DATE Aµf�* x0)0f,' <br /> GEOORAPHK:ALINFORMATmN: COordlrlales Xv27y .' ,V 1./Ir rr(A' l�'re/✓`!1•�% mvnshlp� Range ZO SeCtio.&'� <br /> INTeNoeo USE :;DamestldPrwam !7 4rigationlAgricu tura) Industrial R Water QuaBry Monitoring 'Soil Sampling/Charactenzabon <br /> "!Publin Waley System <br /> mclJ <br /> !f tlafeleFl ha .er m ame ame or nna urn . — <br /> TYPEOF WORK :'.New Well is Reppllacen ad Wag !- Weil AflengloWoOfiralion =Other <br /> Www 41Y8 D)S XMomKvirg Wefl(s) L _Lofwefls -!Soil Budng(s) eO1borogs Geotechnical xol wrin.ps --- <br /> Out-Of-Service Well i_ Out-Of-Service Well Renewal i!CroW-Connection Repair <br /> Nev,Pump .:Pump Replacement Pump Repair _ i:l Raise Well Casing <br /> WELL Co STRUCIOH [ <br /> Drilling Method �,Mud Rotary .Air Rotary : Auger Cable Tool L'Push Point J.( 011 .JG1t('e U16)^a ire,A <br /> Proposal Wall Depth).304t ZOOft Excavation !.r7S indiameter [;Open Sodom I::Gravel PaWGravel Size74din diameter <br /> Conductor Gasing )VI _In diameter I Conductor Casing Depth AM R <br /> Well Casing Diamele � gin.� ThicknessfGaugelASTM Schad y0 i:: Steel Plastic Stainless Steel R Other PVC <br /> Grout Seal Depth I / 17 ft C Nem Cement ram•ggae lbbag/5-fOga)wareh ) nd Camanl sack mlx/T gal water <br /> Bentonite(20%sniids) aL ONer /le Bflwp *+T / ) T( "q Cemen+ <br /> Grout Placement Method 'JL Pumped Free Fafl .l Ogler Retardant I Accelerator(name) <br /> PEOEBTAL Installed By X Driller I Pump Contractor 0. Other 2.Tr __CM 1434 M 04 P)t PPO 1- ja <br /> Concrete Pedestal Dimensions:Wdth_fl Length___I Thick in fl Chdsly Box C'. Stove Pipe <br /> PUMP '] Submarsiblara -jTurbine Omer HP Pump Sat % Sanding Water Level.t <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 MYREQUIRED LICENSE IS <br /> CURRENT AND ACTIVE MTI4 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /J IMUM 24 ND DVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SWNED �^I.J4 TITLE_,-w�., 6'Y?r1 __ DATE y71_/fJ�QLfjf <br /> 1 <br /> i <br /> I <br /> I <br /> I <br /> 1 I <br /> DEPARTMENT U E ONLY Q <br /> Appiwalion Accepted By Date t0_ Area_ Employee l D9,..17 <br /> Grout Inspection By _—..._ Date O SPECIAL Weil Permit <br /> Puml>Inspectior,By_ .._ Date---,,-- WAIVER Received <br /> Sort Boring kafection By._-- Date �nConstructed We110 1 - R <br /> COMMENTS - .M ,—Q� J <br /> PE Sc Received Chackilf Amount Dale Permit/ Invoice Weil IDk <br /> Codes Info B Cash Remitted Semce Re uest# <br /> 9.0Lai - ro f- �• 0 0 <br />