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h (o3a5 <br /> WELL/PUMP PERMIT <br /> SAN JOADUW COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue.STccNToN CA95205-6232-(209)4685420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOSADORESS .{�. / 4'0 <br /> Lt. 11-A <br /> — 7'144 v6 CrrYzIPF cA���eQmA CAq 23 <br /> F (/ <br /> CROSS STREET i 7 r IWl /r MEL✓5 APN J/✓ 2 PARCEL SI L—OLAND USE APPUCATIONN T <br /> OWNER NAME IL /ty PHONE 9S/lr���m-//Af <br /> OWNER ADDRESS O LJC7X J • CITY/STATERrIP PClf eAA„r� <br /> CONTRACTOR Delta Pin PHONE 200-46.5-9625 <br /> COMTRACTOHADDRE93 646 S. California Street CITY/STATE/LP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cr YISTATE MP <br /> jUMSE 0 C-57 R C-61 0 D-09 0 Other NUMBER 724778 EXPIRATIONDATE DS/14 <br /> GEOGRAPHICAL INFORMATION: Coordinate,X Y Township_ Range_ Section_ <br /> IrmNOEO Use Y*OomesBc/Private 0Imigation/Agricuhural 0Industdei O Water Quality Monitoring 0Soil Sampling/Characterhtion <br /> 0 Public Water System <br /> •' ttEMeI.Mh.m Owner. wi.r.,W.Harre N.CN.1 I..H.. <br /> TYPE OF WOW 0 New Wel( 0 Replacement Well 0 Well Altandon/Mod18w8on O Other <br /> D Monitoring Wails) #of wells jcLSoll Boring(s) sabednP' ❑Geotechnical Mafb.N. <br /> 0 Out-OfServioe Well D t-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pum oPumpReplacement X m Re air ❑Rake We"Casin <br /> WELL CONVRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Au 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Cepth ft Excavator, in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing_In diameter / Conductor Casing Depth ft . <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steal 0 Other <br /> Grout Seal Depth R 0 Neat Cement(94 Ib baV5-10 gal water) 0 Send Cement sack lx17 gal water <br /> 0 Bentonite(20th solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other D Retardant/Accelerator name) <br /> Pwefrr L Instaed By 0 War 0 Pump Contractor ❑ Other <br /> Co crate Psdestal Dimensions:Width R Length ItTNck in 0 CNI ty Boz 0 Stove Pipe <br /> (evilP XetbmsnebleO Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY AERISWY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORN WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I.ALSO CERTIFY_TNAT.MY.REQUUIED LICENSE 15 <br /> CURRENT AND ACTIVE WITM THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL- <br /> WORKERS COMPENSATION LAWS, <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED 4 <br /> TMFDATE <br /> T-T-4 RECEIVED <br /> MAY 0 2 2014 N <br /> "N JOAQUIN COUNTY <br /> ENVROVENTAL <br /> NLWH DEPApTE6U <br /> MAT4Eu+� <br /> a DAEADO <br /> Pots <br /> DEPAViMENT USE ONLY <br /> Application Accepted By ILI AAPrrkl Z. Cate 57 2 r t-{ Area O tl I Employee I176 w; <br /> Grout Inspection By SPIT Permit <br /> Pump Inspection B ata WAIVER ReCelved <br /> Sall Boring) poen By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Flocoh ofAmount Date P°�W Involcs# Well WB <br /> Codes Info B Cash Remlttatl Servide Ra oast# <br /> 43162 DSD 5z S,c,,v c, <br /> E11DLyo5 WELL PUMP PERMR <br /> MfAM. <br />