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I` i; F�-7,LL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL.HE`ALTIr DUARTn—off 304 E WESER AVE ,G-STOCKTON CA"202 - �IO9)4GSa r NON-RFTUNDAIILE PERMIT a CALL 2091953-7097 FOR INSPECTIONS EXPIRES I YEAR FROM DA'L'E ISSUED / .ii ll� - J(nl Aunllr:tis c�! � � CltvlZlr��y,r, � %�" -� a ( C- (e PARCEL SIZE LAnD UsE AI PLICArIOH R APN. L '^ � Lam., 77 �� PHONE011'Nr:R Nh'nlr; - �/J��. CITYIS'rATF1Zlr OwNr:K ADt)RrsS P110NF: C(1N'I'NA(JORJ ('UN'I'KAi"1'()K ADDRESS /d /� , I M / ��Gf• IJ_� Crr%'/STAtEIZII' --1--`G � ----. 'I PIIUNE SUBCONTRACTOR it CITYISTATE/ZIP SUBCONTRACTOR ADDRESS l.lc'r:Nsr: ❑C:-57 ❑C-61 ❑D-b9 ❑Other NuMur:R EXPIRATION DATE I! y Township Range' Section GEO(:RAPFIICAL INFORMATION: Coordinates X INTENDED USE ❑t)olllestic/Private IIrrigationlAgrieultural ❑Indusinal ❑Water Quality Monitoring ❑Soil Sampling/Characterization C]Public Water System on+,cl ame ar one um r If diifcrcn,GUIs Oy ncr. I` mer 1yNlcm h1111e TYPr.OF WORK New Well ❑Replacement Well ❑Well AllcrationlModitication ❑Test Hole ❑Other ll ofborings a of boring ❑Geotechnical ❑Monitoring Well{s) �+ #of wells ❑Soil Boring(s) ❑Well Destruction �� Q Out-C)1-Service Well ❑Out-Of-Service Well Renewal ' CJ New Puns ❑Pu`m R+' laccment 0 PUMP Rc air Cross•Connection Repair WF,1,1,CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Q Auger ❑Cable Triol ❑Push Point ❑Other ' Excavation in diameter ❑Open Bottom ❑Gravei u Pack!Gravel Siin diameter Proposed Well Depot Ilq� ❑Conductor Casing in diameter / Conductor Casing Depth ft V ❑Steel ❑Plastic ❑Stainless Steel ❑Other -� Well Casing Diameter in Th'ickncss/GaugeIASTM Sched Wck mix 17 1 water ~ ❑Sand Cement Ba Grout Seal Depth It ❑Neat Ccnlenl(94!b hag 15-10 gill waft J CI ❑Specs an File ❑Specs Submitted ❑Bcntonile(20%solids) ll Manuli+cturcr Spcc solids % Name Grout PIacetuenl MCI"()(' ❑I'lm+pc(l C1 Free Fall ❑(Kier _ ❑Retardant 1 Accelerator(name) Th 1'r.DF.S'rAl, installed 1 [0 Driller ❑Pump('c)jltr;sclur Q l)ther In ❑Christy Box ❑Stave Pipe (� 0 Concrete Pedestal J Dimensions: Width ft Length 11 Thick {_ Standing Water Level fl PtrMP C1 Submersible ❑Turhine ❑Other k!P Pump Set ft ` 1 11r;Rt:}3ti' CIa('I'H Y 'IIIA 1' I ItAVI{YI'ItI:I'Ai[h;l) 'T Inti AI'P[.1('A-1'lON AND THAT TIIE WORK WILL, HE DONT; {N ACCORDANCE WITH SAN .I()AQtI1N COJINTY ORDINANCES, STATE. LAWS. ANT) RULES AND RIIILATIONS, I ALSO CI';R'1'll'1' IIIA'1' MY REQUIRED LICENSE IS CURRENT AND ACTIVE: WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TIiA'1' i AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS.11 MIN1119UM 24 HOUR ADVANCII NOTICF, RFQUIRED FOR INSPECTIONS J� DATE TITLE. �- -... - e.te• Y '•cnw• 54.25' ' [4499•:. � -A U, lI. y ra��A FI /14 .o k,. i :_.(PV:da9 a,o!!:`. .- { _lrG�I+FY.�?,Z� •r .t. ' y l h t�1 V _ IE p�ytNC`A EA ( D E P A R T M E N T USE ONLY l� '67V C►L Application Accepted 13y L% /1 U Arca 2 ! Employee Il)dl i Date ❑ SPECIAL Well Permit Grout inspection 13y �N Date ❑ WAIVIr,R Received I'Pump inspection 13y ft l C/14155 c�il� 1);Itc ld / Constructed well Depth })t tmetxrq Inspection COMM1iNTS s PE SC Recccived ii heck,Yl Amount Dale Permit! Invoice WelI1D# Codes Info as Remitted Service Re uest d 'T i 7-7 0 54' 113ISD s 1D rt o li WELL PUMP PERMIT ii Ell')41,01,106 x'r,.OA