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WELT 'PUMP PERMIT <br /> 1!! SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"FL-STOCKTON CA 951(209)468-3420 <br /> �IVON-REFUNDABLE PERMIT CALL 2091 9 53-769 7 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUE <br /> / N <br /> JOBADDRESS I C�/� 1 CM/ZIP J <br /> CROSS STREET L7 ✓{a uP � APN 2 \ /�I�OV t/7 PARCEL BIZEI�LAND USE APPLICATION It =04-qG/ <br /> CT A Qy SIA r2L <a!✓ <br /> OWNER NAME PROS <br /> DWNERADDRESS /2&b Tnr kT,0u4-- CM/SYATVZIP 4,3-4A� /'ALJ �SJFrl <br /> COWMROR PHONE <br /> COMPACTOR ADDRESS CM/STATFIZIP <br /> SUBCONTRACTOR PHONE <br /> f <br /> UaCOMRACTORADDPPSS CM/STATEZP <br /> LICENSE ❑C-S] ❑C-61 ❑D-09 ❑Other NUMBER EXPIPATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE ❑Domatie/PlivMe ❑longatiorVAgdculluol ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Ch tacton.tion <br /> ❑Public Water System - <br /> IrWo.true c—: .a yoem .me sacs Nave or phone Nusaber <br /> TYPEOFWORK ❑New Well ❑Replacement Well O Well Alteastion/ModifiwUon ❑Test Hole ❑Other <br /> ` ❑Monitoring Well(s)_#of wells ❑Soil Boring(a) kofbodap ❑Geotechnical //4 NOW., <br /> ❑Well Destruction ❑Out-Of-Service Well - ❑0u1-0f-Service Wall Rene I <br /> [3New Pump CI Pump Replacement ❑Pump R a <br /> Repair Cross-CrossR air' - <br /> WELLCONSTRUCTION <br /> DrLilling Melbod C1 MW Rotary 0 Air Rotary ❑Auger 13Cobb Tool ❑Push Point L3 Other <br /> `{ <br /> Proposed Well Depth B Excavation in diameter ❑Open Bottom ❑Gnvel Pack/Gavel Six in diameter <br /> OCoduclor Casing indiameler / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thicknas/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grant Sed Depth ft ❑Nut Cement(94 to lag/J-l0 gat Water) ❑Sand Cement ,rock mu l]Sal Water <br /> ❑Bentonite(20°/.solids) ❑Manufacturer Spa%solids % Name ❑Specs on File ❑Specs Submitted CN <br /> Craut Placement Method 0 Pumped ❑Fra Fell ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Insisted By ❑Drilla ❑Pump Contractor ❑Other <br /> U ❑Concrete Pedestal Dimensions: Width ft Length 0 Thick in ❑Chrlaly Bos ❑Stove,Pipe C1 <br /> PUMP ❑Submersible ❑Turbine C3 Other HP Pump Set_ft Sanding Water Level fi C <br /> 1 HEREBY CERTIFY THAT I 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 yy. <br /> jCURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL I' <br /> t WORKERS COMPENSATION LAWS. <br /> last /I MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE_ L(/,J-1!/L DATE A, 15i`1 Z <br /> I <br /> J O I <br /> 14 H <br /> 1 a//SDE P ARTMENT USE ONL /T <br /> (` Application Acceprd By K'�`�A� Date sZ- "0 Aacs EmpbyalD# <br /> Grout Inspection By��1 Data ❑ SPECIAL Well Permit /JI <br /> Pump Inspection By Imlk ADTA Rue Dare 11-7.3,-04 ❑ WAIVERReceived ��11 <br /> i' <br /> Destruction Inspection By Data Comtructed Well Depth B <br /> `COMMENTS P(a,.Y.6:� v-e.�.w+:4e.( Dw:. S"Fa..a(E di WUi4 <br /> I PE Sc Reedvd Amount ala Permf4 nvofas# We111Dp / <br /> Cda IRfo a ash Remitted I Service rtuat# - <br /> v3rt os� so ez QILIPMj91-7 PLATE 11, Page 16 of 16 <br /> ND aJ-03LW WELLIUMP PERMIT <br /> X/a 61 <br />