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WELUPUMP PERMIT <br /> SAN JOACum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 18EB EAST HAZELTON AVENi7E-STOGKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7 W • i-n ry - �2 _ tJ— I <br /> Jos ADORess �y',"�� o <br /> ('ROSS STREET / <br /> PARCELSME u LAND USE APPutA71ON,'Y. <br /> 1. j v � > ` <br /> i0wmER NAME �, E <br /> /j . <br /> Z J� CmJSTATEfIIa v " <br /> TOWNER ADDRESS - /�� � <br /> :CONTRACTOR VM I <br /> 1CONTRACTOR ADDRESS J <br /> SUBCONTRACTOR ' PIWNE ��j ! <br /> SUBCW,RACT,OR ADDRESS I� IS�TnAfT/lnlZ1rD, <br /> tY iS tf/ exrmATION DATe <br /> L10EN5E 0-57 C-ot 0.09 Other P-2— <br /> 1 NUYBI'R � ' <br /> GEDdRAPMCALINEOR TION: Coordinates X Y Township_ Range Section__ <br /> INTENDED USE DomestiU'Private IrrgatioNAgncultural industrial Water Quality Mdrutortng Soil Sampling/Charaizisn'-stion 1 <br /> Public Water System a.rgne ice <br /> H C+1te:Mt trGT•�Twriar alar Systm <br /> TYPE Or:WORK New Well Replacement Well Well Alteration(Modifip0on Other aat>m+ <br /> C c1 b."i s Geotachncai <br /> MWItormg Well =of wells Soil Soring(s) <br /> c„ervke�µ//dY Out-of-Service Well Renewal Cross-Connemon Repair !1 <br /> New Pum Y Pumo Replacement Pump Repair Raise Well Casing <br /> twat rONSTRucnoN C` <br /> Drilling Method Mud Rctary Air Rotary Auger Cable Tool Push Point Other Q <br /> Open Bottom Gravel PacWGl S <br /> rvvece in diameter <br /> Proposed Well Depen F Excavation in diameter 1� r <br /> Conductor Casing ,n diameter ! Concuctcr Casing Depth n <br /> Well Casing Diameter_in Thicimess)GaugeIASTM Schad Steel Plastic Stemless Slee: Other <br /> Sand Camen; sacit m&TI gal water i <br /> Grout Seal Depth h Neat Cement r94!b ber,1„c;0 gal waer7 <br /> Bentonite(20%solids) Oth i <br /> (Grout Placement Method Pumped free Fall Other Retardant!Accelerator(name) <br /> n�nESTns. installed By Driller Pump Contractor Other in Christy Box ve Pipe <br /> ncrata Pedestal Dimenslons:Width_H La ftr, `-nick <br /> (FUMEup Pump SC h Standing Wzter Level f , <br /> SuUTerside i urJ ne Other <br /> 1 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 i5 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WRN ALL I <br /> WORKERS COMPENSATION LAWS. j <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED POr({�{�,�INJqSnPE'C/TI N'S�-PLEASE CALL(209)9' 69 <br /> SiGN�G Ttit� „J�+' <br /> i 11 I I I j ! I 1 I <br /> I L <br /> I 1 I <br /> •I i I ' ' <br /> i I ' <br /> I I i j i I I <br /> ' I <br /> l I I I iLi <br /> U L 9MENTIAL HEALTH' <br /> d Hs i <br /> IDSERMES <br /> i G011EPA 7MENT E ON Y �Ul�� <br /> SAN�"Yf'ACak Et+�li- G Area vl _mptoyea lDA <br /> j RQ td l3P?+V piWl on Accepted$ Date <br /> / SPECIAL Wel!Permit <br /> Grout Inspection By <br /> Pump Inspection By i =-' --" Data :; WA)vER Received <br /> Soil Boring in, tx 8y' — weConstructed Wel!Depth ----ft <br /> L <br /> COMMENTS <br /> Peretti I I Well IDR I <br /> PE 5C I Received i C5 ( Amount Date � I Invoice tt _ _1 <br /> C0465 tnlo i k3 ii ...J i R.ari:.n c•.^-es RaCac:a -- 1 <br /> ygola //7 Sf�oD75102- <br /> I T I <br /> ' ' � wEu.rotiMa�E�aar <br /> �.Z <br />