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A?� WELUPUMP PERMIT <br /> SANJOADUW COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)468-1420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AnURE•S ggrb"L IJ, p£��I 1W CmrI,., 5,�TOL�.-TOIJ l 9521 Z - <br /> CRDSS S-NtEET f I1,k T I^I L.G N-O APN Q 6`1 -4DW-S Z PARCEL SgEM.-/ LANo USE APPLICATION a a <br /> S@ <br /> tAVNER NAIVE (t RV 14 \h l-I N • E PHONE A <br /> OWNER ADDRESS Z-0-LZ- C. tnV^%TD1t — Q-ZCRISTATERP FfOLT8E-3 <br /> CONTRACTOR NF_ILCIS -IS2k5 <br /> PHONE 26-1-'SP 1 -3'101 <br /> CONTRACTORADDREST Cr1Y/STATETP LDOI I Ll4 gri'21�0 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CT'/STATEILP <br /> LK:ENME C-57 ❑C-61 ❑D-D9 n Other NUMBER UD 4 ExPIRAmoN DATE 4 D9 <br /> GEOGRAPIIKAL INFORMATION: Coordinates X Y Township_ Range_ Section <br /> INTENDED USE C Domestic Pnwte C Img2bOVAgdWItural C Industrial C Water Quality Monitoring XSoil SampunglCharaclertration <br /> ❑Public Water System <br /> If tlMe.rtfi Ov - r n m o • metes neNurroar <br /> TYPE OF WORK ❑New Well C Replacement Well ❑Wel)Alteration/Modificedon 0Other <br /> U Monitoring WSII(B) DoT wells ll Soil BOdng(s) voturnlor )CGeoleehnical Z+ "'dra' <br /> Out-CILSONIOS Well C.Out-0fSerdce Well Renewal C CrossLrnnectlOn Repair <br /> New Pump C Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCmON <br /> Drilling Method 7 Mud Rotary C Air Rotary PlAuger U Cable Tool G Push Point 7 Other <br /> Proposed Well Depth ID -11S R Exnvallon (0 in diameter G Open Bottom ❑Growl PaWGravel Size in diameW <br /> �Conductor Casili in diameter / Conductor Casing Depth _ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schell ❑Steel D Plastic n Stainless Steel ❑Other <br /> Grout Seal Depth It ❑Neat Cement!94 lb bag/STO gal water) ❑Sand Cement seek-mWir gal water <br /> ❑ Bemonite(20%wiMa) SCOther SOtL LEA'T°rtrJLTS 4toLE- PLL-Cbr r,F 4rw. <br /> Grout Placement Method O Pumped LK Free Fell ❑Other _ 0 Retardant/AOCelerator(name) <br /> PEDESTAL Installed By ❑Driller C Pump Contractor ,J Lt�Other <br /> U Concrete Pedestal Dimensions:Width AJ .1 gth AThick in a Christy Box C Stove Pipe <br /> Uff C SubmersibleC Turbine C Other ~ Pump Set ft Standing Water L 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 LR <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT10N LAWS. <br /> , <br /> MINIMUM 24 HOUR ADVANCE NOTICE�REEQUIRED FOR INSPECTIONS 'yam <br /> SIGNID k. F'�� TRLE r rwl EGT 0NLf/NEC K- DATE �'-3—yS <br /> I az POR. SEC.6 J e < <br /> J� O - ae'M nMT RL[ w• MY <br /> i •i u...0 ��.. ® � Y ® 41 0 <br /> 0o n® ..� ,:-• 919 e <br /> I <br /> oe r <br /> c®_ ® E <br /> ' c ® <br /> ID <br /> ,.,.. ,..... U A 1 M <br /> DE A MENT U E NLY <br /> AppW'91ll So pted Oat.-=Ey Area ll P rmi <br /> Iropeaian B pato GK' ❑ SPECIAL Well Permit <br /> Pump Inspection By Data ❑ WAIVER Received <br /> Sall Boring Inspection By Date _ Constructed Well Depthft <br /> COMMENTS 'ZJn.(e-/ /(T,LJ%fah '![.27 �'J..� �J (ig�['",EST`XLr{l� - <br /> PE SIC <br /> Cadiz laid, By C ash Rwitted Date SON]Re Ietst0 Invoice0 Well IDD <br /> ►� <br /> &13 10? �/ <br />