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�0-7 �(p WELL/PUMP PERMIT <br />SAN JOA}WIN COUNTY ENVIRONMENTAL HEALTH DEPT 1966 East Hazelton Av®nue - SYOCrcroN CA 952064292 - (209) 41*440 <br />NON4WUNDABLE PERmT &At I 117AM Aee_ vown-. <br />oa AU -021-00 <br />I � / S��i��.. <br />DUt2EM9 71 � <br />7U -021-00+T tri Cirymp STOCKTON 95206 <br />!caoss muer pU NmA$ r.ANE Apiv 177-26—)12 paacm size 15 5 . .IQ <br />ND usi'AppucA77, <br />OwNaRt�AenF GAN. .TnMLnrjTM rprri`m [�;' NEg AL SAaERVTrE <br />PHONE . <br />OWNER ADDRESS <br />CITYISTATEM STOCKTON Or -1A, <br />CONTRACTOR ha �.,.,fimnrxm(1N .�SRM1�" <br />p,�70RI(4 <br />CONTRACTORADDRess 646 S. California Street & A"`^ � r,�c <br />GrrY/8TAT9/ZIP_ Stockton. CA 09 <br />SUBCONTRACTOR <br />03k <br />suScoNtssACToa Aancu+as PHOtrE <br />License <br />❑ C-57 N C-61 0 D-09 0 Other <br />GrzoGRAPHtCiAL INFORMATION: COordlnabas fit; <br />a1mWy Us,&. 0 DomesuciprtvAtp rnrxff-.Z <br />NUMs6R. 724778 F-01RATIONDATs Q$/)� <br />----- Y Township �— <br />_ a _-.�._. C Irtduatrtal 0 Watert]ual AAonfborin �� Range 9ectlon�_„ <br />q Public Water System �' D 0 Soil 3empling/Charactor(zatlon <br />if dtBor+enc from Owner; <br />r <br />ns <br />E F�1� Q NowWep p Replaoemc#rtt Well 0 Well AftoreBoNModifrcadon <br />a Monlbrinp Wel!(s 0 Other <br />�" � of wells �7' a^oll Bor/rtg(s j, s °l �"a" w Geotechnical <br />❑ Out-OfService W®it 0Out-Of-Service Well Renewal O Cross -Connection Ro a(r ---�-----R <br />❑ New Pum 0 Pum Re lacoment $XPun, Re air p ECEIyE® <br />WEAL orosrnucTlpN 0 Raise Well Caein <br />Drilling Method C Mud Rotary p Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 OtP1er _� 1 <br />Proposed Wcil Depth 4 2018 <br />Excavation in diameter 0 Open Bottom p Caravel Peclt/C3ravel Slzej� <br />0 Conductor Cas)ng In diameter / Conductor Casing Depth QU <br />Well Casing Diameter _ In Thf0knssa/0auge/A8TM Sched ft HEALT NTAL <br />Grout Seal Depth --- 0 Steel 0 Plastic 0 StsiMess Steel p Other H DEP.______ "MEN <br />p ---- % soli 0 Neat Cement (g4 /b hag's, 10 gal water) 0 $and C <br />�e (2Q% soitd0) o Other sack mlx/7 gat water <br />Grout Placement <br />M <br />pFresF0 OtherItsy p prlp� p Pump Contractor p <br />ba Pedestal Dimenalorts: Width Other <br />srkt <br />❑ Christy BOX -0 <br />I HEREBY CERTIFY Pum $e <br />THAT' I HAVE PREPARED THIS APPUCATTON AND THAT THE WORK WILL BE DONE INft n UYetter level ft <br />JOAQWN COUNTY ORDINANCE, BTATL L.AW8, AND Rt1L.Bg AND RL'L�LlLATIONS. I ALSO <br />CURRENT AND ACTIVE WITH THE CAUFORN[A CON CERTIFY THAT �ORDANCE WITH t3AN <br />WORKERS COMPENfiATlON LAWS. TRACTORS ST'AT'E LICENSLx BOARD AND THAT .I AIW NY CREQUIRED CEl l'NNS AIS <br />LL <br />24 HOUR ADVANCE NOTICE REQUIRED f~OR INSPECTIONS <br />31QNLq <br />Tans CEO <br />Applfoatlon A="ted By <br />Grout Inspection By E <br />Pump Inspection B Date If <br />By N ��1111 C�� 1�,kki SPECIAL Well Pe <br />SoilBortng lnsp�On By Date <br />i1Va+VER Received <br />OMMENT3 Date . Constructed Watt Dooth <br />Areae <br />me ID# 112VLEW <br />imtt <br />wE1.t.IPUMP PERMfT <br />In <br />