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WELUPUMP PERMIT <br />SAN JOAGLIN COUNTY ENvtRCk cNTAL HE.ALTN DEPT 1868 East Hazolton Avenue - STOCKTON CA 95205-6292 - 1209) 4683420 <br />NON-REFUNDABLE PERMIT L ALL '2A9 853-i65i FOi21ti3 cCr1oN� EXPIRlES� I YEAR FROM DATE ISSUED <br />JOO ADOREss ��"� _ C. • / Crryrzip `G �+�'i[/lrr� /�✓+c.�� nN <br />CROSS STREET l' (�L b <br />APN PARCEL SIZE,�L &jko USE APPUCATION d <br />rJwNER NAiaE s�46�5 __ PHONE <br />OWNER AOOREss ��p�:/1'rE j� �'�vF CITYISTATEf W <br />CONTRACTOR PHONE <br />CoNTrucroR ADORE59 CITYrsTATFI2,P/ <br />_ C. 44; <br />SUBCONTRACTOR _ PHONE _ <br />SURCOhTRACTOR ADDRESS _ . CITY/STATEIZW <br />LICENSE .-57 D-09 Other NumsER 0 ExPwAnoN DATE_( --� <br />GEocnAr43CA1INroRwncw: Coordinates X Y Township Q. ­ <br />INTENDED <br />NrENDED USE KDomestioPrivate Irrigabon/Agriwltural Industrial Water Quality Monitoring Sod Samphng/CharactenzabonY <br />Public Water Systen <br />Y Od!«•N imm O.mcr n y, em �,r.. nn M �. a .m +e r — ' <br />-i r/en AncrationlMOOlbcatton Other <br />Monitoring bVell(sJ It or «ehs Soif Ban s sot Gnrv; • ct [. •r.,-. <br />nGl) Geotechnical <br />Out -Of -Service WL -11 Out -Of -Service Well Renewal Crass-Conned:on Repair <br />New Pump k Pumo Reotacement Pvmn Re w D.r.e <br />�Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Etcavabon in diameter Open Bottom Gravel PacldGra�el Size.n diameter <br />Conductor Casirp in diameter / Conductor Casing Depth tt <br />Well Casing Diarxter _ in Thicimess/Gauge/ASTY Sched Steel Plastic Stainless Steel <br />Grout Seal Depth it Neat Cement (94 lb beg/5-10 gal water) Sand Cement sa:A mixi`7 gai waer <br />Bentorvte (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEOEST Installed By Driller Pump Contractor Other <br />i Concrete Pedestal Dimensions: Width it Length ft Thick in i i Christy Box Stove Pipe <br />(Pum 1( Subrners Gle. 7urbne Other HP Pump Set R Standing Water Level !6� <br />1 HEREBY CERTIFY THAT 1 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 IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL. <br />WORKERS COMPENSATION LAWS. <br />DEPARTMENT USE ONLY <br />Application Accepted By Date- ­-?. /?-�1 I <br />Groat Inspection Dale _ <br />Pump tnspecl�on Date <br />Soil Boring n By _ _ Date <br />:OMMENTS� 'u/ S811i <br />Area -"C.4 141.q Employee ID4 _, zS,GOn'L <br />SPECIAL Well Permit <br />WAIVER Received <br />Construct It Depth ft <br />PE <br />Codes <br />SC Received <br />Info 8 <br />ec <br />sh <br />Amount ate Perm w Involceg Well ID* <br />Remitted Service Re .Bent <br />43,1 <br />v5v ��r <br />l788 <br />:>3-� zg ,o <br />ZX, <br />tM+.ra <br />T <br />:i3 <br />13 <br />)UNTY <br />AL <br />MEINT <br />