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int: //:,gI/* �2-� /VQ I iso L7 <br /> rl WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL Heat.TH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES T YEAR FROM DATE ISSUED <br /> q�� 1 1 //''++� <br /> JOB ADDRESS 10 <br /> ,ZO I L.L"ye u'q RCM/\ (� CT17JP )I _ 1 l�) L/'IYJ A <br /> CROSS STREET CryI1 Wy I `1 L, APN /7 U ; I if D 2L PARCEL SIZE i �-J LAXOaU9E APPucATONII b� <br /> OWNER NAME / t 11P krn.t 1\ t PHONE <br /> OWNER ADDRESS )Z C(�-I^^�1.,,kir L I I ,,{{�I)l-.rr CRYISTATEMP Sy d hf 6 /'"• ti r) W S <br /> CONTRACTOR AJe 0 H Ae! 1 4 4c . /L (PHONE Laq- 3617,-3252l <br /> CONTRACTOR ADDRESS 9OZ. Tnd M4T�,d Nom/ CRYI$TATERJP WJI 0 ci5L-LlU <br /> SUBCON TRACTORN/YPHONE 1111 <br /> SUBCONTRACTOR ADDR585 A11µt CITYISTATEZP N/p <br /> Ucewsi C-57 C-61 D-09 Other NUMBER LL`i U(2� ExnRATIDN DATE 3/'f J)/U,13, <br /> GEOGRAPHICAL INFORMATION: CocadlnatazX Y Township_ Range_ Sactlon_ <br /> INTENDED USE DomesNWrivate IRIgation/AgncuNural Industrial WSW Quality Monitoring SON Sampling/Characterization <br /> Public Water System <br /> edwerameaaa»ner. - WalarSyrosMn. n ems or re ue <br /> TYPE OF WORT( NeWWell ReplacamentWell Well AlterdtioNMadlNcatlon Other <br /> Monitoring Walls) Rofwells SoiIBodrg(s) Pa1em�9� 5(Gectechnical—X dedlrgs <br /> Out-0t-Service WBn Out-0T-Sercke Well Renewal Chow-Connection Repair <br /> New Pump Pump Replacement Pum Re Ir Raise Well Casino <br /> WELL CONSTRUCTOR /j, <br /> Drilling Method Mud Rotary Air Rotary 'Alger Cable Tool Push Point Other <br /> Proposed Well Depth3 tj _ft Excavation a in diameter Open Bottom Gravel PacklGravel Size M diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_In ThlcknewVGaug9iASTM Schad Stsel Plastic Stainless Steel Other <br /> Grain Saal Depth ft Neat Cement(9}Ib begr5-10 ga/wefeq Sand Cement — 3OCk mixO gal Water <br /> -7�tonile(20%sdids) NOthe! <br /> Grout Placement Metlwd Pumped XFmF.1 Other Retardant/ erator(name) <br /> PEOLU& Installed By Ogler Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_ft Length 6 Th Ck_m Chdsry Bos Stow Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Szmdm9Water Level ft <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 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 /> MIN U 24 HOU 8�/ANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED �`Y TInEVs+NNet DATE .4 / <br /> Tr <br /> Lo <br /> :�� <br /> UZS <br /> Z <br /> 4¢C <br /> O�JFJ <br /> �W¢ <br /> a 44 <br /> N = <br /> u <br /> DEPARTMENT USE ONLY 1n <br /> /y� Date_ Area. Employee IDM zZ'�r� <br /> Application Accepted BY �� <br /> Grout Inspection By Date ^: SPECIAL Well PermR <br /> Pump lnspecg Date WAIVER Received <br /> Sol Boring In tion Date _ Constructed WON Depth it <br /> COMMENTS - <br /> `fCLC/7/-I: <br /> PE SC Recaind Checlall AmountImrolve0 Well IDN <br /> Codes Info B Cash Remitted DoesServiPermelce W0 <br /> 71z I}J �� ��l �� 3-IIAG S�W7W.AOLI <br /> TJ n� WEIL/RAPPERMIT <br />