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`fr <br /> WELL/PUMP PERMIT <br /> ;3a4Joaow.>1COV::TY EwR0!AvEPiTAL KEALIH DEPARIVENl ima EAST HAUtion AVENUE-STOCKTO:r CA 95205-(209)468.3420 <br /> `. __ CAIt 209 953.7697 FOR.INSPECTIONS _ EXPIRES 1 YEAR FRQn+_t)ATE ISSUED <br /> NON-REFUNDABLE PERMIT -_,�,.-_ <br /> .71"rF-4 95-3'.0 <br /> Jon ADDRESS _ ( / JS�r LJl1}}(<°'1 ,----- cnymp',` i z' ------ <br /> CROSS STREET J•�`1J Ile APN. 7G Ar .� [;.� ?PARCELs-ze��LARO USE APPLICATIO-10 <br /> orr:'ERNArtE _ e -� � ('- r;'flats _.__ --- -_ <br /> PHo a .4/ <br /> O'WNERADORESS 1&&-4610 _?—LlsalieO J cc` _ — CITYISTATEIZIP_ <br /> 1 /1 <br /> CO!4TRAC10R �' r1�� S�•�..L�nGlr�fli�1S� ss ''!- __ ..____.. CnY/STaTELP <br /> CONTRACTOR ADDRESS PlHrO(// <br /> 'ti:E ('-&7`i'-`i�SJb•SlGn7 <br /> •.i7Gl <br /> SUBCONTRACTOR ki 1A--_ u PHONE <br /> SUBCONTRACTOR ADDRESS- "_ - CITY//ISTATEMP - <br /> r_ LICENSE 57 GOl 0-09 '1 011ier - NUMBER -u" C�V EXPIRATION DATE <br /> GEOGRAPIeCAL 11:FORMAl104: C00rdlnatOSX Y Township, RAngo Section— <br /> (MENOED UsE I DomestbYrivato r l trrigatton/Agrlwkural I IndUslrlal !1 Water Ousfily t.looltortng ?T Soil Sampling/Characterizallon <br /> i i Public V(ater System ct a- sraf n9f1!.crn-�- <br /> TrnE 91YLOM New Wel i Replacement Well t:Well AlleratioryT=lodncation i Other - <br /> -1RlonitoringVJeT(s) #of v.-els :":Sal Boring(s) >"r['Anz, ;vGeotechncal -%dc x:nja <br /> +Out•of-Servke Well t 1 OW.Of•Service V+felt Renewal :i Cross-Connection Repair <br /> -,NoaFlom�_Pranp-Re <br /> placemeM <br /> WELL CONSTRUCTIO' <br /> Ddiling Method •s Mud Rotary ',Air Rotary WAuger I:Cnb!o Tool Push Print r Other <br /> Proposed Well Depth-j(- /! It Excavation__L_to diameter I Open Botton :t Gravel PacWGravel Size M d+'ameler <br /> '1 Conductor Casing In diameter I Conductor Cas',ng DepRT 4 <br /> Well Casing Diameter_In Thtdmess/Gauge/ASTM Sched 'steel i l Plastle i I Stainless Steel ,1 Other <br /> Grout Seal Depth_fl ,:Neat Cement f94 1b bogr5-10 gal wator) i i Sand Cement _sack mtr17 gal water <br /> ,I Bentonite(2054 s0':ds) r i OthEI S Of e"ffoqy <br /> Grout Placement 14sthad "Pumped 1 i Free Fat !t Other I.,Retardant I Accelerator(name) <br /> PEaEaiQ Installed By 'i prtfrr 11 Pump Contractor :r 011ier ----- <br /> -� Concrete Pedestal; Dimensions:Width_fl Length it Thick In +.!Christy Box '1 Stove Pipe <br /> SubmersW. * l Tud*w ?Other _. NP---_- Pump Set ft Standing Water Level __—ft <br /> I HEREBY CERTIFY THAT 1 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 MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 4 HOURl,�y� NOTICE REQUIRED FO(R INSPECTIONS-PLEASE CAH (209)953-7697 <br /> SIGNED ! (a � L! TITLE "+"Y' 17 r1 (}U'.e( BATE <br /> -� . -- - _ ---- -- -- - - - -5214 <br /> N <br /> -- - - - - _ - - - -- - -4( A Tt p T <br /> DEPARTMENT USE ONLY <br /> Application Accopted By Date. <br /> t 1� Area Gc?{ tj�� Employee 1130(�}L7.tNcl(i4 <br /> Grout Inspecifal By- + -_� Date -_- FI SPECIAL Weil Permit <br /> Pump Inspection Bypals- 1) WAIVER Received <br /> Soft Boring Inspe,lion By_ ale-�-�" Construclad Well Oopth R <br /> COI.VF I$ Arl <br /> L. -�� ---- -- - <br /> PE._._ .... SC Received hock(►! PonnlU -- _.- - <br /> into -- <br /> Date Invoice# Well lot <br /> I <br /> Colles B)r - iA - RomlHod - Som <br /> E+•D a][-i V.fLL r:Lti'PF'EAS 1 <br /> anvr� <br /> 6- <br />