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/:Do <br /> WELL/PUMP PERMIT ' � <br /> SAP JOAQUIN COUNTY ENVIRONMENTAL HEALTB DEPARTMENT 304EWESERAVE 3"FL-STOCKTON 2 - ( ) J <br /> NDN+REFUNDARd PERMIT CC ,pCALLp/209 M-7697 FOR INSPECTIONS / EXPIRES I'YEAR <br /> I FROMSDATE <br /> /ISSUED' W <br /> JOIADDRPS6. ..'����/h �IM& -' 8SIT// ,yx� CPTvizlp Lt1 4A., Vr f503O <br /> CRI STREET 11,WAV ZI6 APN l �~�Va��IFAARCEL SIZE 26L—LAND USE APPLICATIONN <br /> i! <br /> OW`1Me0.VAMC IlA—/LI PHONE <br /> OVIINER ADDRESS / CITY/STATE/ZIP <br /> CO�NTMCIOR 4yy/&/LAJ/,If1d1J? <br /> PHONE /3/ -�y�pS(./ �3 <br /> CHY/STATEfhPCACrORADBRE66I <br /> SCONTRACTOR J�Z/�I y11II1` <br /> PNONE z0f�3� Z <br /> SA1! <br /> y WNTRACTOR ADIN E66 CITY/STATFJZIP <br /> L ICII1 ENSE57 ❑C-61 - ❑D-09 ❑Other NUMBER+23-%5-Cl 5Cl EXRRATION DATE --0 <br /> GEOCMPHICALINFORMATIONI Ca^rdi^eteb X Y Townbhip Range_ Section <br /> n <br /> meriic/Private ❑IDigalion/Agricultuml O Industrial Cl Water Quality Monitoring ❑Soil Sampling/Chamcted>ation <br /> ❑Public Water system <br /> ITdinmenrrmm0woer: aur ynm, oma nurr e <br /> TiTEOF WORK Nev Well ❑Replacement Well ❑Well Alteration/Modification 13 Other <br /> ❑Monitoring Well(s) d ofwells 11 Soil Boring(s) aafbornp ❑Geotechnical sofawinp <br /> O Out-Of-Sanaa Well ❑Out-06Se via Well Renewal * ❑Cmss-0annasion Repair <br /> ❑New Pum ❑Pum R lacament ❑Pum Repair <br /> WELL CONSTRUCTION <br /> Dulling Method 13 Mud Rotary Air Rotary ❑Auger ❑GNIe Tooi fj.Push Point ❑Other OE <br /> P posed Well Depth aA0 ft Excavedan — indiameter ❑Open Bottom e�Gravel Pack/Grovel Size in diameter <br /> ❑Conductor Casing indiameter / Conductor Casing Depth it <br /> Well <br /> Casing <br /> Diameter in TM1ickness1Ga c/ASTM Schad ❑Sral �Plasdc ❑Stainless Steel ❑Other 'J <br /> Groin Seal Depth <br /> Diameter <br /> 13 Neat Cement(94 lb hag/5-10 gat water) Sand Cement <br /> /0• 3 sack mix 17 gal water <br /> ❑Bentonite(201%solids) ❑Manufacturer Spa%solids_% Name ❑Specson File 13 Specs Submined <br /> O out Placement Method O Pumped O Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDLfiTAL Inatalkd By ❑Driller 13 Pump Contractor ❑ Other ` <br /> Q ❑Coneate Pedestal Dimensions:Width ft Lang h ft Thick in ❑Christy Box ❑Stave Pipe <br /> �T PY�MP ubmersible ❑Turbine. ❑Omer HP f� tap Set ft Standing Water Level It <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 4 <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATION& I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> T WORKERS COVENSATION LAWS. <br /> MI U U ADVANCE NOTICE R b UIRED FOR INSPECTIONS �-1 <br /> S eD' Tr1'Le DATE7--29-06 <br /> K/ <br /> I � � <br /> f. <br /> I i <br /> i <br /> 0 -P- j <br /> J N, N <br /> P <br /> J:SI3s-U. E_O <br /> Applicafion Aaepled By R v6 Area Employee IM <br /> Grant Inspection By Dam � 1,7-�d6 13 SPECIAL Well Permit Y[y7 <br /> Pump inspection By / Oates/d ❑ WAIVER R¢C¢iV¢d I <br /> Constructed Well Depth ftl <br /> COMMENTS / 1 6 '16EIAIJ t <br /> a,PE SC Received Chee AmountPeenov <br /> OdH Info B Cash Remitted -Date Service a uest#TO lnvela M- WeII IDN <br /> O <br />