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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46&7420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES,1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /�+ <br /> CROSS STREET OXY//// // ---API Oil OVO��PApOEL SME LANDUSEEAPKICAAIN/e,1lR, ` <br /> 57 <br /> OWNER NAME Alkz;I /(�hQ� PHONE <br /> OWNER ADDRESS (//�{�J,.� ;ei-e.< Ad CmISTATE/LIP..Y!/-/�L/JILJ/flyl)e+e-4 <br /> CONTRACTOR lr 1 ; �iP1LL/ P,HlONELY// /72-,975]7 <br /> CONTRACTOR ADDRESS�0 <14r h�1z-i i .Ql/ CmISTATEMP;f[lGu ,,.,P IA 957II2rt <br /> SUBCONTRACTOR - PHONE <br /> SUSCONTRACTOR ADDRESS Cm,IST�ATE�ZP g <br /> LICENSE C-57 C C-61 _r,D-09 -'Othe! NUMBER /�j% 7r EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: CoordinatesX Y Township Range_ Section_ <br /> INTENDED USE JT Domestic/Private InigatbNAgncultural Industrial 'I Water Quality Monitoring o Soil SamplinyChamctenzation <br /> Public Water System <br /> Il Elllerenl M1am Oxrar: —Walei3ysl¢m Flame-- —�-�mleo�eme m�IpieNum6er--- <br /> TYPEOFWORK 1411,lew Well i Replacement Well " WBII Alteration/Ma9gcation 'I Other <br /> I Monitoring Well(s) R of Wells -Soil Boring(s)_ t Wboengs Geotechnical t of term, <br /> Out-OI-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair <br /> New PUMP F PUMP Replacement i Pump Repair Rake Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary Air Rotary Auger AY <br /> Tool Push Point I. Other <br /> � AY <br /> Proposed Well Depth <br /> It Excavation �.J in diameter Open Bottom )(Gravel PacWGravel Size indiameter <br /> Conductor Casing in diameter / Conductor Casing Depth h <br /> Well Casing Diameter A in Thickness/Gauge/ASTM Sched,YZ9 Z/ Steel XPlastic C Stainlesa Steel .:Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag3-10 gat wale,) i Sand Cement /40. .3 sack mW7 gal water <br /> I Bentombe 120%SGIKM) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By N Driller Pump Contractor Omer <br /> Concrete PedestelADImeneions:Width R LerI N Thick��In t Christy Box Stow Plpe <br /> Pu MP SubmerslMe Turbine Other HP Pump Set /zb R Standing Water Level it <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 /> MINIM 2 OUR A VAN TICE REQUIRED FOFiJ�NSPECI'TIONS-PLEASE CALL(209)953.7697 <br /> SIGNED TITLE,yr!/�aCr� DATE <br /> t . <br /> ° d <br /> r 1 . <br /> 56 1 <br /> = 1 I -E Aidai• u <br /> DEPARTMENT USE ONLY <br /> Application Accepted B e,,Data Area 4191 Employee IDR <br /> GroutInspection B - - Date Ise- SPECIAL WGII Permit <br /> Pump Inspection <br /> By Date x. WAIVER Received <br /> Soil Boring Inspection By Date .Constructed Well Depth_tee <br /> COMMENTS �1NL.y4Ah .MSpa+L(tEiUln,'Jl:n ^^`"" h <br /> PIE I SCReceived CheckN Amount Date ParmNl InvolceR WBII IDR <br /> Codes Into By Cash Remitted Service Re uestR <br /> 937 °d 0 I .' RfW-7020 <br /> oa p <br />