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WELL[PUMP PERMIT ` <br /> `SAN JOAWIN COUNTYENT9RONMENTAL HEAL"DEPARTMEM 304E WEBER AVE 3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ::1 CALL/(209)953-7697 FOR INSPECTION5 EX/PIKES 1 YEAR FROM DATE ISSUED <br /> rOWNERNAW& <br /> CITY/ZIP_�CL � p <br /> r , <br /> .,/ /(^/ ` /1 �J4 � ARCLLSIZE LANDUSEAPPUCATION#�� <br /> � STREET +�•/I}�^ �' APV / ',��� I'/� r / [1 Q LJ <br /> PHONE�� CT'ISTATE/ZIP <br /> ESS ^� rS 4 //7 /LPHONE5 3 P Z 7L_i ADD +� CRYISTATEIZIP f/i/t7Q H/C"a"fL <br /> PHONE <br /> SUBCONTRACTOR <br /> COY/STATCIZIP <br /> $UBCOITTMCT'ORADDREss � Q_I�'7 1` <br /> LlceNs¢ C-5] ❑Cfil 0 D-09 ❑OtherNUMBER�L,.L2.`a E%PIMTIONDATL , N <br /> y TOWncM1IP_ Range__ Section_ <br /> 6LOORAPHICALINPOILNATTON: Crordimn" X LIC <br /> INl h orpUSE WPmn-IidPTiv'mstc ❑IrrigatiodAgricultmRl 0Industrial ❑Winer Qunliry Monitoring ❑Soil Sampling/Chamcterimtion <br /> ar <br /> ❑Puamrm.rom Ownem uer Ywm eine oixac� um <br /> TVPe OP WORK ' 1ev.'Well O Replacement Well ❑Well AlwrtioNModification Other cofmnnp C <br /> O Monitoring Well(s)_gof wells OScil Boring(s) aoT�� ❑Geotechnical <br /> O Out-OfSmice Well 0Out-0L-Service Well Renewal ❑CrossC...action Repair <br /> ew Pum O Pum R Iacement O Pum R it <br /> WELLC NSTRULTION <br /> +� Drilling Method�ls4ud Ronny ❑Air Rotary O Auger O Cable Tool <br /> ❑Push Point ❑Other <br /> Proposed Well Depth 2 ft Excavation_J�_in diameter 00 <br /> pen Bottom ❑Gravel Pack/Gravel Sim in diameter <br /> ❑Conductor amng in diamete / Conducmf Casing Depth <br /> ❑Seel -- Plastic ❑Stainless Steel ' ❑Giber <br /> Well Casing Diameter in ThicknsdGau6dASTM Sched J <br /> a Grout Seal Deptlf},�'t '__R O Neat Cement(9416 hag/J-1Ugul-11) Sand Cement ZJ sack ma/7 gal water <br /> ❑F mMnite QUA solids) O Manufacture Spec%solids__% Name ❑Spas on Flle ❑Specs Submined <br /> Grout Pluemeet Method Pumped OFra Fall OOther ❑RmaNant/Accelerator(name) <br /> RDLSTAL IBdalHd By 'A, nMoer O Pump ❑ Other <br /> ❑Concrete Pedemal Dimenuone:Width R length ft Thick in ❑Christy Bos O Stove Pipe <br /> PMP bble OT in C!Other HP pump S RSunding Wamr Level ft <br /> tracu1 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. 1 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 /> INIU HOUR ADVANCE NOTICE RtEQLIMD FOR INSPECTIONS _ <br /> �.- TITLE DATE <br /> SIGNED <br /> r <br /> A UN O N <br /> L <br /> - � a <br /> haaa <br /> { <br /> L <br /> ` J D PARTMENT UB LO LY <br /> D r Area Employee IDR iii✓ttt , <br /> Application A.eple By <br /> .. 110 �/'.li-, / <br /> Groin InspectioDam ❑ SPECIAL Well Permit <br /> n \ -'/ Dine _ ❑ WAIVER Received <br /> Pomp InspecH n BY --=a ' <br /> r0a, R <br /> CMMIEN ted Wall De n <br /> COMMENTS?vt� LL'1^-C� �1�"'e � e -� y <br /> haaa PE SC Received Che Amnant ate Fermi/ ImuAce4 Well Im <br /> Chea Into C''h Re Z A u � lceR Realg <br /> oOSer3 ga _ <br /> e S w vo d <br /> 0 O � <br /> wELLPUW rEPMIt <br /> EHDaantom <br />