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WELUPUMP PERMIT <br /> i SAN JoAwN CowTY ENMONMENTAL HEALTH DEPARTMENT e00 EAST(NIMH STREET-STOCKTON CA 45202-(209)46"20 � <br /> NON-REFUNDABLE[PERMIT vy�J CALL(208)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> In <br /> Joe ADOREBS y�,[ fi/tt,y,,,� ���.�+���J CSR D <br /> CRoa9 8TREET�j r yAf0/��/��-I`��RD APN - ,—..SUE JELAND USE APPLr-AlmN## <br /> ONNER NAME NA-r9A CAC r r PWWK Z09- .03-5- 1/7/ <br /> OWNER ADOFMSS 5K/f C _ CrTHSTATFMP <br /> CONTRACTOR PHONE <br /> CoNTRAc7OR ADDRESS CITYISTATE0 <br /> SUBCONTRACTOR _ — PIroW <br /> SUBCCNTRACTOR ADDRESS CrtrtSTATEfZW <br /> LMENae C-57 ❑Chit U D-09 7 Oster NUMBER EXPIRATION DATe <br /> GEOGRAPNICALINFORMATION: C00nibutesX Y Township_ Renoe Section_ <br /> INrENPEO USE V.DomestztPrifuate L kr9B Kx/A4rFaMDret ❑Industrial 7 Watar emaSb Manitanng 7 Sod SamplingtCheFedemallon r <br /> Cl Pub0c:Water System or �f <br /> If Ci<wvu trvmC+nier. —K� CUM <br /> TYPE OF WORK I I NOW Well I Replacermrrt Well I i Well AllerationfModificaton I I Other <br /> ❑Monitoring Vftks) #of watts C Sod Bor"a(s) - s or Inrto 7 Geotachnicai M of noAnOs O <br /> 0 Out-OfSeMce Wed C Out-OfServlce Well Renewal C Cross-Correction Repair. <br /> 9 New R Repair 7 Raise Well Casing _ V <br /> WeL,L fe9 STRUCTION _ --- <br /> '+ - Drilling Method ❑Mud Rotary Air Rotary ❑Auger 7 Cable Tod ❑Push Point ❑ Other J� <br /> Proposed Well Depth_ft Excavation In diameter Lt Open Bottom ❑Gravel Pack/Gravel Size in diameter 1 ! 1 <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Oiarneter_m ThldvresslGauge/ASTM Sched 7 Steel ❑Plastic ❑Statnlesa Steal ❑Other <br /> Grout Seat Depth_ft ❑Nest Cement{94/b bag/5-10 gal wateh ❑Sand Cement sack mLr17 gal water <br /> ❑Bentonite(20%solids) 7 Other ; <br /> Grout Placement Medtod a Pun ped Free Hai L Otho u Retardant/Arcelaetor(nems) <br /> P!'DESTAL Instalted By Driller ,Pimp ContracW L Other <br /> 7 Concrete Pedestal DtmensIo,na:WIdM R Length R Thick to C Ch(tsty Box rt Stove Pipe <br /> PUMP Submersible Turbine ❑Other HP r�L Pump So__a 2 R 5 Water Levol R <br /> I 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- I ALSO CERTIFY THAT MY REOUHRED 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> . Tm�}ii-'tcC,11'�' lK2QF_!' DATA lD 2r3 0°1 <br /> —TIT <br /> i <br /> I <br /> - o <br /> DEPARTMENT 11,17,0" Y r <br /> Application Accepted By ... — dY Araa Empkryae lQ# 5 � <br /> Grout Inspection By SPECIAL Well Pertn4t <br /> Pump Inspectfon By ate WAIVER Received <br /> Sol BoMg In By / Qate Constructed Well Depth R <br /> Comm S <br /> E 100SC Ra W" eq Amount Dam Service 0 <br /> Pe+iInvoice 0 Well IDO <br /> Codes Info Remttted <br /> 14319 p 3q <br /> E'D 43-M WELL PUMP PER,/rT <br /> a*.Oe <br />