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WELL/PUMP PERMIT <br /> SAN-I OAOUIN COUNTY ENVIRONMF.NTALHEALTH DEPARTMENT BOO EAST MAIN STREET-STOCKTON CA 95202-(269)498.3420 <br /> NOWREFUNDABL�E!]PE�RMIT / )CALL-((.209)953r-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOS ADDRESR IW CITYIOP LINtI{✓�... IJ�yC: ^� <br /> > g <br /> � <br /> `N pARCEt 82fi�?A LAND Uee APPLIGTDN#____,________ <br /> OWNEA NAME IL{NN�'i Ah�t4+ t1.AIC,Y, J PHONE l _l�r Ci1 <br /> OWNER ADDRESS _.r�. LDh i'11 L...... _-.- CITYISTATEMM.4j" �h r•1 %>LlS <br /> I <br /> CONTRACTOR N tni Lel t/ bt,111at-.Sit PHONE S-F�-J�J2£fJJ(( <br /> CONTRACTOR ADD W !(`I A 1b t' JZ d CIIYI5TATEJEI O:Je`dCry Ct el'5:0 / <br /> SUBCONTRACTOR __- PHONE <br /> SuecoNTAac,OI ADDRESS /CITYIyS�TAATEEILIP <br /> LICENSE /C-57 C-Sl D-09 Other NWIBER Jerky --f___. E%PIRAT,ON DATE„ �C� J� <br /> GEOGRAPHICALIWORMATIDN: COOrdIRM"% Y Township_.......__ Ramll BSWan_ <br /> NlTexo[o UBE DomestlnRrNete .IrdgatorVAgriculturel .IncusfVal Wa1M OuaiSy Montodng Soil Sampling/CRamcteriz[,tlan <br /> Public Water System <br /> � A. <br /> TYPE OF WORK fNew Wep Replacement Well Wel AHaralloonvotllBCafil _ Other <br /> MonitoringWel :. "auxingo as Will <br /> Ka)_ #of wens Son Bon ogle) Geotachnic <br /> . Out-Of-Service We# Out-Of-Service Well Renewal ICrass-Connection Repair <br /> Now Pump Pump Replacent" Pump ReFl�,air Raise Wel Casino _ <br /> WELLCONSTRMCM5 <br /> iDdlling Mathod /Mud Potary ;,AG Rotary ,- Auger ;;Cable Tool Push Point :. Other <br /> Proposed Woll Daplh TJ'� -th Excavalion t'" <br /> ... in dla crater Open Bottom .(Level PacklGraval$iz —_ J_-. In climate, <br /> Card Casing Casing in diameter / Conductor Casing Depth <br /> D. meter I �-� t <br /> Welt Casing DIn Th,cknpss/Gauge/ASTM Sehe l "Jr 1.Steel Ipls Stainless Steel [:Other— <br /> Grant Seat DesDU_Z,3_-__Is Neal Cement(9a to baGIS-,O g,T(water) :_Sand Cement_.__ sack mlrq gal water <br /> /Bentonite(2096 sontlel Other <br /> Grout Placement Maewd Pumped Free Fall -.Other Retardant/Accelerator(name) <br /> P TAL IneWled By Driller 'YPump Contractor Other _ <br /> ..Concrels.Padsat l Dlmsnslons:Width_K Le tglh N Thick In Chrlery Bo% .. Stove Plpa <br /> _ IIS SuDmersble. Turbine Other IIP—_ Pump Set _ It Stan ding Water Level it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK LL 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> — <br /> $IGNEa TITLECI=flYJ <br /> —_77,1,� _ <br /> {. . <br /> er. . Hivr'4 :111 <br /> R <br /> t <br /> loss — <br /> 2 h N N <br /> E 'ARTfAENT USE ONLgY J���,( <br /> Applialbn Accaptod Bly <br /> v' Dale!1I L� Area_-f GroulInspector,B ^ r<„L--ice Dale _Sell Permilt <br /> � Pump Inspector,BDate _._. WAIVERReceived <br /> Soil Boring lnapacHon By Date - � _ Can cged Well Depth ft <br /> COMMI <br /> hills <br /> PE SC IteoeleEW CMpks/ Amount -_ - PermN! _-- <br /> Glal 11110 <br /> Cash Remflted �1e. Service Reauesi Invulu,# Well IDs <br /> em wws weumu"a+Penun <br /> ,rent <br /> r <br />