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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE-PAF{ '1868 East Hazelton Avenue-STOCItTON CA 95205-6232-(289)466.5420 <br /> NON-REFUNDP.BLE PERMIT ALL � ?61-7697 FOR INSPEL(IONS EXPIRES 1 YEAR FROM DATE ISSUED In <br /> IN <br /> i a <br /> CITy21P <br /> JOB ADDRESS <br /> r, /1 J`�' a <br /> L/ I - `PARCELSI �f 'r" AND(1SE APPLICATION# <br /> li C": APN A m <br /> CROSS STREET <br /> ry , PHONE <br /> ' OWNER NAME t - <br /> (( t � CITYISTATE/ZIP <br /> OWNER ADOREss J r /C� <br /> PHONE <br /> CONTRACTOR <br /> ,,,���j /J J V <br /> CONTRACTOR ADDRESS CITYISTATEIZIP��•� �J`h �. I <br /> dT <br /> PHONE <br /> SUBCONTRACTOR <br /> CITYISTATEIZIP <br /> SUBCONTRACTOR ADDRESS <br /> ^ 1 EXPIRATION DATE <br /> LICENSE <br /> —4-5 -y <br /> 61 ��D-09 �r OtherYdDMaE <br /> Y Township_ Range Section__ <br /> GEOGRAPHICAL IDIFORMATIOM: Coordinates X 1.Soil Sampling/CharacterizaUotl <br /> INTENDED IJSE omeRdPrivale I hrigation/Agrindutral V Industrial I Water Quality Monitoring <br /> •Public Water System n er on a oma ur anc umoor <br /> ' —_-- 1l different tram Owner. Y� <br /> TYPE OF WORK y+;New Well --Replacement UVell Well Alteration/Modification vaf6 Other f:nI oorinars <br /> Monitoring Wells) #Of wells 'Soil Borings)) Geotechnical <br /> Out-Of-Service Well Out-Of-Service Well Renewal RaieWellasiCross-Connection Repair <br /> ' 20T1 PUMP Pump Replacement r Pump Repair <br /> ' Raise Well Casino <br /> QUELL CONSTRUCTION <br /> Drillitag Method ry'Mud Ro Air Rotary Auger Q,ahle Tool -j Push Point I Other <br /> I lj�, n diameter <br /> Proposed Well Depth ! _ (a'_R Excavation _in diameter ! Open Bottom Gravel PaddGravrJ Size + <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Steel ;K,plastic -Stainless Steel .Other L \ <br /> Weil Casing Diameter in Thickness/Gauge/ASTM Schad sack mixl7 gal water `V <br /> Grout Seal Depth ,'ac _R Neat Cement(941b bag/5 t0 gal water) (Sand Cement-� <br /> Bentonite(201%solids) -Other <br /> _I Retardant!Accelerator(name) r� r <br /> Grout Plecoment Me <br /> umped Free Fall i Other <br /> ' PEDESTAL Installed ByDnller Pump Contractor,; ! Other R Thick in Christy Bou Stove Pipe <br /> Concrete P dostat Dimensions:Width R Length r <br /> PUMP r• Submersible!!Turbine �I Other <br /> Hp Pump Set-2 'Li It Standing Water Level ) fl <br /> 1 <br /> NTH <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWSHAND RULES AND A END GULATIONS. I ALSO CERTIFTHAT THE WORK WILL 13EDTHAT MVONE INC REQUIREDELCENSEAIS <br /> ' CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT J AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> NOTICE R?LIIF'i <br /> SIGNED LJ?/� 7 ° J l /,d�a�',f'vyt? TITLE ''^�� DATE .l <br /> y <br /> �:f-ter <br /> v aaG _ n v t <br /> S C 'Q r..out,lr? <br /> � V ;Ef;TfIL <br /> ' J ` <br /> DEPARTMENT USE ONLY <br /> ate Area ,_. Employee ID# <br /> ' Application Accepted By OKI <br /> SPECIAL Well Permit <br /> ateGrout InspectionWAIVER Received <br /> ' Dale I <br /> Pump Inspection It <br /> ' Dale Constructed Well De ih <br /> Soil Boring Inspection By �G L-av i1C-Q L e%o <br /> COMMENTS lrcc� T NCT t f <br /> /7-1. <br /> Amount PeRe Invoice# Well IN <br /> PE SC Received Cheelt#1 Date Service Re uesttf <br /> ' <br /> Codes Info B Cash Remitted <br /> LL 93, <br /> Lr-3�v o�-z <br /> ,5-3 r <br /> WELL IN IMP PCRMrr <br /> a,oafoe <br />