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WELL/PUMP PERMIT <br /> SAN JOAOUW COUNTY EN111ROBYENTAL HEALTH DErARTWN7 600 EASTMAN STREET-STOCKTON CA 95202-(709)16&3420 <br /> NON-REFUNDABLE PERMIT ,, CALL <br /> 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADoREW m21r Quy{— 7XC U� �Y1� L4 C1 "1cJ2 is �y <br /> CROSS STREET �+[ T�Q APN 0Qn1-GQO Ply aZE L4i-'3 LAND USE APPLICATION <br /> OWNER NAME rim ktyjac — p4bal <br /> OWNER ADDRESS � �7 CRYISTATEMP <br /> CONTRACTOR <br /> �11,12�'►'mryns �� I1 S •m� ,� PHONE2�-a31-S-4C) <br /> CONTRACTOR ADDRESS 21W W 11 J7J(_��-�vT- CrrY(STATEIZIP <br /> SuscoNTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZP <br /> LICENSE -57 - C-61 D-09 „Other NumsER•�6 91?.)1 E.T.O.DATE <br /> GEOGRAPHICAL INFORYAnON: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE '!stir/Private _ Irrigation/Agricultural Industrial E�Water Quality Monitoring D Soil�SampinglG��haraclL�'���Public Water System <br /> If ddhrrt from Ownerarr <br /> TYFf OF WORK 'I New Well ]Reptaament WeR -Well Alteration/Modification L Other <br /> I Monitoring Wells) ._#of Wells :1Soll Boring(s) rordoA ps Geote&nirai raecrcQ, <br /> Out-Of-Service Well -Out-OfSeMce Well Renewal G Cross-Connection Repair <br /> New Pump Re ent Pump Repair _Raise Well Casing <br /> WELL COWTRUCTION '� <br /> I <br /> DrIIWQ Method C Mud Rotary Air Rotary Auger =Cable Tool -�Push Point ,- Other <br /> Proposed Well Depth k Excavation in diameter <br /> Open Bolcom D Gravel Pack/Gravel Size in dlarrreter <br /> C Canducigr Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameterth <br /> In ThickneWGeugeIASTM Sed D Steel stip 7 Stainless Steel C Other <br /> Grout Seal Depth k Neat Cement(94 lb baW5510 gat water) 1 Sand Cement sack mud7 gal water n <br /> Bentonite(20%solids) Other •+ <br /> Grout PWcwn*nt Method _Pumped -i Free Fag E Other D Retardant!Accelerator(name) <br /> PEDESTAL Iruttilled By J Driller -Pump Contractor Other <br /> C Concrete Pedestal Dimensions:Width R Length ft Thick In D Christy Box D Stove Pipe <br /> Submersible TurWne _Other HP Pump Set ft Standing Water Level it +� <br /> I HEREBY CERfih 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. 1 ALSO CERTIFY THAT MY RECKARED 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 /> IMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN EE� TME DATE <br /> i <br /> .N <br /> DEPARTMENT USE rONLY <br /> Application Accepted By �t ---- Date 'tel ZZT/Y Area Employee IDA <br /> Grout Inspection By �i Date ❑ SPECIAL Well Permit <br /> Pump Inspection By C _s / Date s �/2, ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chadd/ Amount Date Perm W Invoice# Well ID# <br /> Codes Info B Cash Remkted Service Re uest# <br /> `fad! sr ;� L S}.ry L' S'r�cc; S� <br /> EHO 43-06 Y:ELL'PUMP PERUff <br /> 62&09 <br />