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WWI <br /> WELL/PUMP PERMIT <br /> fltd/ SAN JQAOUIN CouiITY ENVIRONMENTAL HEALTH DEPARTMENT BOO EAST MAIN STREET-STOCKTON CA 91202-(20%498-3420 <br /> ' <br /> NOW-REFUNDABLEPERMIT CALL 20$ 553-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �n <br /> Jas ADDRE36 0�* j• A1Yit yi 1q,64sr ri►oaii F-D. CITYMP �T04 KTO A) <br /> IF CROSSSTRFET f.. klL-DJ-Cj�. I.ANt�A�P�N 0175`300-31 tS� <br /> PARCELSiZ _ALANOUSEAPPLtcanaa# - $� <br /> OWNER NAME Mammmmo, a t_x PHONE <br /> OWNER"DRESS1304``/1 me c.,sTAT-z,i S-7omro ii CA q5210 <br /> CONTRACTOR - VE, A�,L.�r�� 1 /f <br /> PHONE <br /> 517��"/t�1(1���w O,3 <br /> CONTRACTOR ADDRESS `Lj.t,.� Y��• fix CITYISTATEMP �Y 1J�Q CA `�{��2.Z <br /> $DBCOKrrtACTOR <br /> 7 f sg �- - PHONE <br /> SuecoNrRACTOtt ADDRESS C"ISTATEM <br /> I <br /> I LICENSE C-57 11 1 1 1 669 I t Other NUMBER ADSEXPIRATION DATE EXPDATE 2 I 201 <br /> GEOGRAPHICAL INFORMATION: COordinateS X'- W-ZS 1 Y_2e-041 Townshlp_ Rari Section <br /> INTENDEd USE '2 DomesfcJPrivate G InigationlAgricutiurel 0 Industrial 7 Water Quality Monitoring KSOil Sampling/Characterization <br /> 7 Pub6G Water System _ <br /> Ifawwftt rrom Owner. a �em eme n c atmo,pnom umwr <br /> TYPE OP WORK 1 New Wag i i Replacement Well 1 Wen Alteration/Modi icatlon X Other Zro Tr-" alU <br /> Monitoring Well i #ofweae 0Soil soli eofi YGeolechnirai ,^Roth°rrngs <br /> ]Gut-Of-Service Well :I Out-Of-Service Well Renewal G Cross-Connedion Repair CV <br /> 7 New Pump D Pump Replacement E Pump Repair 0 Raise Well Casing <br /> }SIO LCONSTRucn4nt <br /> I. Drilling Method 7 Mud Rotary 0 Air Rotary Y..Auger D Cable Tool 0 Push Point 0 Other <br /> i <br /> Proposed Well Depth 3 4,_„_,ft F.11i 8 in diameter 0 Open Bottom u Gravel Pack/Gravel Size in diernmer <br /> -1 Conductor Casing In diameter I Conductor Casing Depth It <br /> Well Casing Diameter In ThlcknesfdGaugeIASTM Sched 1 I Steel t Plastic I Stainless Steel 11 Other <br /> Grout Seal Depth ft u Neal Cement(94 0 bagr5-10 ge)wafer) u Send Cement sock mixt7 gal water <br /> 013tentonite(20%solids) XOther JUWyaWjr4ySA] <br /> Grout Placement Method 1 i Pumped 1 Free Fell I I Other 1 Retardant/Accelerator(name) <br /> PEOESTAt installed By c Driller O Pump Contractor 7 Other �+ <br /> I Concrete Pedestal Dlmensions:Width R Length ftThick in i c Christy Box 11 Stove Pipe 'h 4 <br /> "ti 1 <br /> Pl1MP 7 Submeii Turbine 0 Other HP PurM Set it Standing Water Leval 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 AC WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL _ <br /> WORKERS C NSA ON LAWS. <br /> TYIi UO �DVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED Tlt'LlE rr ��G SII DATE �, L •� <br /> \-4)1 <br /> V1 <br /> FAT ily-Vr <br /> I <br /> r � <br /> ED <br /> 20)4 <br /> cout4 r <br /> FF1 tv fl WTMF')ST <br /> EPARTMENT US ONLY <br /> Application Accepted By ate010 Area FmptOyee ID05q! <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By ate / WAIVER Received <br /> Sall Baring Inspectl n ,Date _ /�C> Constructed Well Depth rt <br /> COMMENTS Y C ,e"l'!r ��[� [G' GL44.� [/F1..] rr�I577C^• <br /> PE SC I Received Amount Dale Permit! Invoice# Wellll7# <br /> Codes Info B Cash Remitted Service R uest# <br /> i 3'1 ISO 2{a w. U <br /> I <br />