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WEL.L.I PERMIT <br /> ""SAN JOAQU N CouNTY ENVIRONMENTAL HFALTH DEPARrMEM 600 EAST MAIN,STREET•STOCKTON CA 95202 -(209)46,6-.3420 <br /> NC}WREFuNDABLE PERMIT CALL(209',M-61a e0ii:5Npt= EXPIRES 1 'YEAR FROM DATE 15511E0 <br /> _. <br /> JOEa ADDRESS (7 /V. til/4 B Jt C P !'t t�c. CrNizip <br /> 4ROSS STRJEETAP •S I -Oz o- V PARCEL SUE _LAND USE APPLICATION H <br /> OWHEi NAME Pxi COQ It,Pot-4 F e 0)) (Z-q <br /> OWNER ADDRESS Zoo iy W4'9r yl i7' Av{ CrTY1STATEJZ1P_15104 ft $k2T <br /> A� ___—__ <br /> iCGirTRACTGn .dtz_r y1C'+t `S30) 6 <br /> Q$ j ! PH/ONE A pq <br /> GaN3t;rcroNADDR€ss v� �l - lpA4 '(YLrrrk!$ {�' ri SII <br /> p'� �`t, CIrrlSTarel2lp tr �'�/� <br /> SuacoNTaacraR L/:FAt(/��i ?1V�1^pyj�r, ;rLp l Q.yihem. PHONIE X760) q L-SPI <br /> SUSCONTRACTGR ADDREss V CIr'YISTATEtZIP i�Gi h!�A.S �i� bio i�� _.. <br /> LICENSE :- �* E~$# 0-09 Other NUMBER �7�C�V� Exr-tRAnoN DATE ��1Ftfif (Ci 1 Q <br /> shp a) <br /> V Range Section <br /> Coordinates X Y �� <br /> IN;"eNb�o 115E Oamesficl€'eivafe lnigationlAgrictlltural Industria! OC iMa[er Oua,Sry <br /> PUN!,, Water System fvic,nlfUring ".;Soil$ m <br /> aplinglCharauerizaiiun <br /> If <br /> L-� !I tl€lfvrenl Sam Otw;rr —'-�---4Je';ar aY-•trm nn*e holt .srie ar not kur,._ei <br /> - ...�,_ --,....,...,..,...._f <br /> TYt=;:Or tNO�R+F( ";New LNell is Replat:ernenl Well s:' We#f AltaretronlModification _Oher _ <br /> A&W LIF 017 I�4GrIiForing Wells) .`#Of Wells Soil Boring(s) "Oi 4o"�' x of barmy <br /> Geofeduiical <br /> Out-O}-Service W01 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum] '=Pump Re lacernornl P11n3 Fee air <br /> fEl. CaNsrRrscnDH ..,...._ Raise WeEi C�-sing <br /> Drilling Method :. Mud Rosary _i Air Rotary Auger _;Cable Tool Push Point X Other <br /> Propaf <br /> sed Well Depth)3a 4"2 g0ft Excavation 7,7' in diametef 2 Open Bottom Gravel POWGravcl Size x Q in diamefar <br /> Conductor Casing iy41 in diameter I Conductor Casing Depth IV' _ft <br /> We If Caging 014meter in ThicknesslGaugefASTM Sched „J i:.� Steel F'tastic $f2inles5 Steal it Dt)er VC <br /> Grout Seat Dept <br /> h -__zsl Neat Cemenf(©C�fb ba91S 10 kyr wafer) Sartd Cement .SRck mhR gs;water <br /> Benlonite(23%solids) OC Othee x-q, <br /> Grout Placement Method k Pumped Free Fall _ Outer Retardant l Accelerator(name) -�"- <br /> PEDESTAL Installed By A Driller 5,Pump Contractor a Other Ll11 —CG rdx$ o+►n wrrslG�a 6rsJ A <br /> N <br /> „ Concrete Pedestal Oitnensions:Width ft Lenuth rl Thick in `:Christy Box Stovepipe <br /> PUMe .i Subm-mttler: Turbine :3 Other _ HP --'Pump Sef_ 7 Standing Water t.evek rt �O <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONEIN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORMNANCES, 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 /> WORKER$COMPENSATION LAWS, �+ <br /> �. ,IMUM 24 HO t DRIANC ;NOCK£RF LpRFj) FCS <br /> TITLE <br /> PIT-- <br /> ILL <br /> I l l I if r <br /> 4 ! <br /> I�� tt <br /> -j—:L <br /> DEPARTMENT U E ONLY -- t G - <br /> AppIica1ioo Acceptea By -- Date _ . -- Area_ ......_ Employee iD# f <br /> Grout Inspec6ort fay- DaCc O SPECIAL Weil PeCrnil � <br /> Pump tnspecFor.6y Date WAIVER Received <br /> Sod Boring' action 8y _,�. - Oede Coostrucied Wek�D t if <br /> COMMENTS <br /> PE SC Received Cheek9l Amounf Permit/ <br /> Caries Sofa_ B Casft Remiftetl Date W Service Re vest# Invoice!F Welt lug <br /> DI <br />