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tt. WELLlPUMP PERMIT <br />SAIr JOACKN COUNTY EWRONNIENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 468.1420 <br />NON-REFUN'JABLE PERRnT CALL 208 953-7697 FOR INSPECTIONS gXPIRES I YEAR FROM DATE ISSUED <br />L i <br />JOa ADAREa3 1 / L I I crr rz P t <br />iCRWs STRFtT ►�./IRr-�--I Zc� _. AgPN �CJI fX7 PARCEL SMF. 4.ANO Use APPuwnON # i� <br />(OWNER NAME ,/�3_ t�ycr i � / L/��-1L PHON£ 1-9—t! `1- <br />OWNER ADDRESS 1 yy� tl CRYISTATEILIP 2 <br />CONTRACTOR _ '��1/J v^r L P ONE J j <br />CONTRACTOR ADDRESSy _ �P' �...3 CnYISTATERIP �r <br />S49CONTRACTOR PHONE 1 <br />SUBCONTRACTORADDRESS CIITTYII'S]TATERIP /! p <br />LICENSE e"7 <br />= C-61 7 D 09 �- Other NIJNBER! • � 78 EXPIRATION DATE <br />GEOGRAP34CALINFORMATION: CoordinatesX Y Township_ Range Section <br />INTENDED USE omBSllr:lPdvale . Irrigafion1Agncultural -- Industrial Water GuaiRy Manitadng ? Soil SamplingrCharacterization <br />Public Water System <br />If elffaraft from Owner — waftf byalem Nam r0no <br />Tree OF Wogx } New Well D Replarzment Well D Well AlterationlMcd Ocation Z Other <br />r: MonilDdng Well(s)__ N of wells C Sol] Badng(s) trn(barnros ' i Geotechnical 0ofbed <br />r Out4)f-Servir& Well : Out -Of -Service Well Renewal �- Crass -Connection Repair <br />Mew Pum '! PuMp Replacement 7 Purne Re 'r <br />WELL CONSTRUCTION <br />Drilling MethoQ)WMud �ROa D Air Rotary .7 Auger Cable Tod - Push Point Other_ _ 1 <br />Proposed Wap Depth �u — It Excavation. in diameter -: Open Bottom .,ravel PadlGravel Size in diameter <br />Conductor Casing in dlamouir I Conductor Casing Depth ft <br />Well Casing Diameter,<in / gicicnesslGauga/ASTM Sthe� a StaeI�YF lactic = Stainless Steel J Other <br />Grout Seal Depth " it C Neat Cement (D4 fb begIr10 gal water) Sand Cement .�%cif _ saclvm&a gaf water <br />i j Bentonite (2D% solids) C oftr <br />Grout Placement MethobX3�umped ' Free Fall J Other = Retardant I Accelerator (name <br />PEDESTAL Installed By Drili; i Pump Contra - Other <br />Concrete Pedesis! Dlmerleione: Width ft Lengl tt Thidt in C Christy BDx 3 Stow Pipe <br />phi : bmersible� Turbine J Other kP Pump Set It StandGng Water Level it <br />1 HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N 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 (.AWS. <br />INIMUM 24 HOUR ADVANCE NOTICER�E�ED FOR INSPECTIONS <br />SIGNED _ � '"�'"" TITLE a'f DATE <br />_w <br />g <br />1� <br />1 <br />Application Accepted 8 Date ?�' IF Area Employsee ID# � <br />Grout Inspection Date 2ZV,920 D SPECIAL WO11 Permit <br />Pump Inspadon Date -7 3 r3 WAIVER Received <br />Soil Bering Inspection By Date Ccnatrueted Wali Dopth R <br />COMMENTS S � %/ t? f - lam, <br />T— <br />PE T SC Received hoc Amount Data Perms Invoices{ Well 1W <br />C0d1_s Info BY ash Remitted <br />COW <br />aV a 7 C/00 <br />MA �SQB WELL lPUAfPF'ERRn7 <br />I g28N7 <br />