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WELUPUMP PERMIT j <br /> ♦.prT,�--_+y SAN joAQ"CQUNTY ENVIRONMENTAL HEALTH DEPARTMENT 6OO EAST MAIN STREET-STOCKTtN1 CA 95202•(209)469,U2E I. <br /> NON REFUNDABLE PERMIT CAI-L'209{95S-759", FOR iNSFEC70INS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 3l Y+IS ►�s so.� Iloa./ CriralP 1--P4 e-y < <br /> Joe ADDRESS .r <br /> �etrinpfy,� iPits .7Ta <br /> CROSS STREET APN ?SS— �PARCeL SUE yr� Frt LAND Use APPJCATioN4 <br /> PNDN / zS 96 <br /> 3- <br /> ftf-1 <br /> OWNERNAME `Y2t <br /> m 1I <br /> T.r4 4��S•3M �y <br /> /1 /C4 S S 4a�_,_ Clrr/SrarelLlP <br /> OWNER ADDRESS _ X205 <br /> CONTRACTOR E!e,ff�f; PHONE S3 5 O-28i'/ <br /> P U, �oK /S9 CRrrSTATE"_ r/7LY «' !S 7S <br /> CONTRACTOR ADDREsB <br /> PHONE <br /> ISUBCOMRACTOR _. <br /> Ii gLtUCaBCIOSNETRACT..ORADDRESS. . - <br /> _ CITYISTATF/ IIP <br /> Numm 73y9 <br /> EXPIRATIONDAtf 3t /Q <br /> C-57 -.G61- —D-Dg- kOthernn 24 tf/d <br /> y__ <br /> Township_ Range Section_ <br /> GEDGRAPIacAt.INFORMATION: <br /> IN FyCoordinates X_,_._ <br /> 10 .USE V OomestfUPnvate . Irrigation/Agricultural ,. Industnai .Water Quality Monitoring .. Soil SomplmgtCharactenrehon <br /> �_T Public Water System er em —'Co ame a Dna u <br /> 11 OWerem from Omer: <br /> ::New Well Replacerranl Well _Well AlleraUorUModRwtion =Other a or bomgs <br /> Monitoring Wells) Mor was Soil Boring(s) _ s of wing* Geotechnlwl. <br /> Ou.cf-Seance Well / Out-O m We enewal _Cross-Connection Repair <br /> New Pu Pump Replacemetl mp R air _ Raise Well Casio -__� <br /> W ELLCOPlA4TI 4CTION <br /> Drilling Method " Mud Rotary Ar Rotary .. _ We Tool Push point Other <br /> Proposed Well Dept <br /> R Excavation in diameter Open Bottom '_'Gravel PectdGravef Sea in diameter <br /> Conductor Casing m diameter ! Conductor Casing Depth <br /> Well Casing Diameter_in ThidcnesWGauge/ASTM Sorted =Steel _Plastic Stainless Sled .Other Ir <br /> Grout Seal Depth ft m <br /> Neat Cement(94 lb bag/5-10 gal water) _Sand Cement sad mixR gal water <br /> Bentonite(20%solids) " OtIwf ` <br /> Grout Placement Method - Pumped :Free Fall - Oiher Retardant t Accelerator(name) + <br /> PEDESTAL Installed By . Driller . Pump Contractor Other— <br /> Concrete Pedestal Dimensions:Width ft I.ength ft Thick in _Christy Box : Stove Pepe <br /> IpUUP )(Submersible_Turtme . Other _ HP Pump Sat Z er Level S ft <br /> I HEREB-! CERTIF` THAT.I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> l <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND RCGulAT:ONS. 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 /> IMU?A 24 HOUR ADVANCE NCT?CE REQUIRED FOR INSPECTIONS E;^ <br /> � <br /> _ TrrPt •'t. E� DATE Df <br /> SIGNED i.E I <br /> i <br /> I <br /> I - <br /> • t __ 1 <br /> I t <br /> a <br /> Af <br /> _ - _ - , �AO�j��r IN C� _ ._ -•._�. <br /> ��pgRMgLM)� <br /> DEPARTMENT P SE ONLY <br /> PypIMaODn AOClQIed BY�. ---- -...— Data.� 1� r'� Area Employee IIF s�Q. <br /> Grout inspecton By Date SPECIAL Well Permit <br /> Pump Inspection By Oace -- WAIVER Reoehred <br /> Date Constructed Well Depth ft <br /> Soil Boring In on BY p JL ' <br /> COMMENTS <br /> PE SC _I Racelved Ch l Amount Data �—Permit! Invoice g Well IDM <br /> Codes _ B Casfi ! Remitted Service Request 3 <br /> L- i I WELL PvMP PERMT <br /> wo-M a6 <br /> arouoa <br />