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WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENv1Ro NMBiTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(2091468-M20 <br /> pr; <br /> NON-REFUNDABLE PERMIT 1CALL(249 953-7697 FOR iNSPECT'.ONS EXPIRES Z YEAR FROM DATE ISSUED <br /> JOB ADDRESS / / D Q w' _`L' CITY/ZIP <br /> r I <br /> �3ARCFLSEGR0.58 STREET �5 rt APN ` io <br /> LAND USE APPLICATIONS m <br /> r2,0-,I ro <br /> OWNER NAME Ti � tq/ L�nJ /�� PHONE / E3 Y- `7 S1 j <br /> OWNER ADDRESS /It a V ��' -L ti/t>°- r` CITY/STATNZIP C'J 9 Sao I <br /> CONTRACTOR �✓es� Loas�- St-f, tr tt+olec 'c D3A (GAJ/y Ele�7r`RPNONE �?.s X35- 2 b/Y <br /> CONTRACTOR ADDRESS P—,,. 13.x ( CrTYISTATFJZIP �f4 G y C.'9 y S-3 7 F <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS !� CITY/STATEIZJP <br /> LICENSE C-57 C-61 _D-09 her r�?l e-i a NUMBER 7 ii f 5 3 EXPIRATION DATE a�/3x/10 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTFNOFD UsE DomesbctPrivate ..InfgationlAgricultural ndustr al Water Quality Monitoring _.Soil Sampling/Characlerization <br /> Public Water System <br /> M Oinerenn hom Owner a er y­. anteNa—Of one u r <br /> TrPEOF WORK _New Well i.Replacement __Well Alterab n/ModlBwtion Other <br /> G Moniloring.Wel(s) ofwelsz- S ' Barings) -- `sof lwrinps_ „`y,-Geotdchnical' sof boAnpa I <br /> Out-Or-Service t-Of-Service Well Renewal =Cross-Connection Repair j <br /> New Pump"'. ,Pump Replaceme Pump Repair _.Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r Mud Rotary = otary �Auger . Cable Tool _Push Point :! Other tf <br /> Proposed Well Depth ft Excavation in diameter _ Open Bottom Gravel Pack/Gravel Size in diameter <br /> i <br /> Conductor Casing in diameter / Conductor Casing Depth It ; <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sdred Steel 7 Plastic = Stainless Steel Other r <br /> Gmut Seal Depth n =Neat Cement(941b bagl5-10 gal water) :j Sand Cement sack mizl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _ Pumped C Free Fall _Other Retardant/Accelerator(name) j <br /> PEDESTAL Installed By - Driller Pump Contractor Other - <br /> =Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Bo: = Stove PI <br /> peIRVj <br /> I <br /> P jSubmersible_Turbine _: Other HP__3_0 Pump Set Z S_Z it Standing Water Lever�_R I <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT.THE WORK WILL BE DONE IN ACCORDANCE WITH SAN i <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANIJ REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE 130ARD AND THAT I AM IN COMPLIANCE WITH ALL E <br /> -- - —---y=-VVn-RKERS.COMPENSAT.ONIAWS._- ,_ <br /> MI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �- Ttn.E�"'LP ' �-�l't•�L,'4'� DAT6 // ._ ? <br /> I <br /> A i EYM�N D <br /> GE�vE <br /> 9 <br /> zoo <br /> - k - - N JOPfl��MGoug <br /> EtySP+1 <br /> DEPpR�M� <br /> 1\ 1 <br /> EpART USiE Of1LY <br /> Application Accepted BY <br /> Date Date « 3 Area Employee IDT [ <br /> Grout Inspection By DateSPECIAL Well Permit <br /> Pump inspection By - ate Z WAIVER R0G@IVed <br /> Soil Boring Ins n By Date Constructed Well Depth R <br /> COMMENTS i LGJiJ�J/L�(3TL ✓ ����L�7 <br /> PE SC ReceWed Chec Amount Pe 1t( Invoice 0 Well ID# <br /> Codes Into B Date Cash Remitted Service R uest 0 <br /> 'f3�t a�$� Sv.t� rI 0 .�'2 c�05�"7'l W p03ZZ D <br /> EHD a3,,X WELL IF'UMP PERMIT <br /> 8,04108 <br />