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)OM, <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 96202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT c CALL 209 953-7697 FOR INSPECTIONS )EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS j��OD wi/.� J-4a-z NT !\V�. CITYrzIP IrOAI <br /> CROSS STREETT-" 4,14 A-Q APN <br /> . �J3-0-10^C� PARCEL SIZE LAND USE APPLI.CATON# <br /> OWNER NAME S-yiIC� L LC— PHONE <br /> OWNERADOREa3 CQCQfriA CITY/STATE(LP tycif( /9 9 <br /> ;'L, <br /> 0 <br /> CONTRACTOR 14A'0eASVA) &5�6C4 V' PHONE 2©q-,3(0 -S'70[ <br /> ) <br /> CONTACTOR ADDRESSqDX74 'r-NO"S-T 4 CITY/STATEZP &VpI t-K Q!EV&2 <br /> SUBCONTRACTOR _ -_ PHONE <br /> SuecoNTRACToR ADDRESS CITY/STATE/LP <br /> LIGENeE 557 C-61 D-09 Other NUMBER 0O EXPIRATION DATE <br /> GEOORAP14CALIWORMAflON: CoondlnatesX Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Inigation/Agricultural Industrial Water Quality Monitoring ('Soil Sampling ara erizatwn <br /> Public Water System <br /> 177 IR eiMeimt lien Omer Wate,System Nam am Or Nusw <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) 4ofWhip Geotechnical rdlxnrgz <br /> Out-0/-Service Well Out-O(-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WEu CONstRticnoN <br /> Drilling Method Mud Rotary Air Rotary ���Cable Tod Push Point Other <br /> Proposed Well Depth�5 R Excavation#-�in diameter Open Bottom Gravel PadUGravel Size__in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in ThicknesslGauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth__ ft Neat Cement(94 lb bag7S10gal water) Sand Cement sack ixl7 gal water <br /> Bentonte(20%solids) Other SptL- C-kTyilvkS 1401,6 PC44-,4' _�� G✓' <br /> Grout Placement Method Pumped 4fPree Fa Other L'Retardant I Accelerator(name) <br /> PEairIeL Installed By Driller Pump Contractor <br /> Concrete Pedestal Dimensions'Width Length It Thick In Christy Box Stove Pipe <br /> Inymp Submersible Turbine Other HP Pump Set <br /> it Standing Wafer Level R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATIOtrAND 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 YNTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR An,;A*ICF NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED_ TITLE jn.vJ ELT mor,A-cf-t!/�TA <br /> — �sf T N' . <br /> - "AN-2 D <br /> o <br /> ?015 <br /> Aa <br /> 'Ro /N CpV <br /> -- oc An 4C <br /> ear----- AFM' <br /> DEPARTMENT US�Et0NLY <br /> Application Accepted By Date AreaG `1 Employee ID# <br /> Grout Inspection By Date SPECT L Well Permit <br /> Pump I ate y� WAIVER Received <br /> Soil Boring I jo Date i Constructed Well Depth R <br /> COMMENTS ZAP L <br /> / ------ <br /> PE SC Received CheckMl Amount Date PertnW Invoice# Well IDS <br /> Codes Into -Ta- t— Remitted Service Request# <br /> tz11 1 31-9 vR007118 <br /> EHD 43 e6 WELL(PUMP PERMIT <br /> 904M <br /> -(nli/*-•dY . 37 - 30 Qin <br />