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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3u"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT} J / CALL(204 953-7697 FOR INSPECTIONS EXPIRES I YEAR PROM DATE ISSUED <br /> 1 JOB ADDRESS V / / 9 <br /> �•�' r W /ZD CITYIZ]P / V / �3 7 <br /> m <br /> t CROSS STREET I l APN v� 'Z'310 ;20 PARCEL SIZ r LAND USE APPLICATION# <br /> OWNER NAME _ R o i PHONE J/'�/ 1? 7,4-( � <br /> F ' n �q {/��a / J��/ 1 y <br /> OWNER ADDRESS �ll�!fl �0A. A �� Qty CIITTY/STATE/ZIP 0+r—t �1I➢p/+ `-�� y bi l <br /> F CONTRACTOR �/4 ](�/ 1 y LYS 5 PNONE <br /> CONTRACTOR ADDRESS_ � - �-+r7rJ 'I ,a # CITY/STATEIZIP t/V iC4 9?6- fy_ 9— <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZI <br /> r1 <br /> I LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER ioI� �p 10 T <br /> r <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section _ <br /> i INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial �;- -'Wa er lit"'M to ori `b.F` °]$aril�' hilracterization <br /> FI ❑Public Water System ! /; A <br /> If different from Owner: ater ystem ame <br /> onlac ame or Phone Numbler <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modificatiotl"T ll�IfT 4I le��Cl1/ twithout <br /> ❑Monitoring Well(s) #ofwe]Is ❑Soil Boring(s) <br /> t e� Mg CoMpl[glede <br /> _ = <br /> ,��E( orborings <br /> ❑Well Destruction ❑Out-Of-Service Well ZI �rviceIRI Dit `pNewPum ❑Pum Replacement ❑Pum Repair b3l-QnectilRion <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> E <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom Gravel Pack I Gravel Size#5 n diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth <br /> Well Casing Diameter _ in Thickness/Gauge/ASTM Sched c7 D�0 _ ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth Gg..`ft Neat Cement(941h hag/5-10gal water) ❑Sand Cement .rack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method mped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed BY ❑Driller ❑Pump Contractor thcr <br /> Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP_ Pump Set �Y%d ft Standing Water Level 7w ft <br /> I 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 IS <br /> CURRENT AND ACT1V E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM ATION LA <br /> NI 24 H D ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED - TITLE ��� (/( � DATE <br /> i <br /> .39t04 <br /> \ 3916 <br /> .39 <br /> 1.6 NAIL Z Y d <br /> 3570 3573 <br /> ' BRrllGE SPIKE 6 NAI <br /> ;d- & SR <br /> r <br /> 39033gg 4 <br /> - ..,.- 6 rn C0�LN. 953 <br /> ... 3907 \ at'ug- <br /> �O <br /> M no r <br /> O `J <br /> I <br /> SN O COL IN O N <br /> l VI o i <br /> FENCELINE SURVEY ' <br /> ScRcc. I"=2oo' FOR VICTOR BULL <br /> Or T88 PROPERTY DESCRIBED AS TR$RBST$Ary, DP THE <br /> 9A67 HAZY, 07 TSS NDRTHSA,ST QUARTER Or smMONS a <br /> TOBNSI7 5 SOUTH,RANGE 4 EAST,1LD.IL 1 <br /> AN.111INC0RP0I TED AREA — SAN JUMUIN COUNTr <br /> : sTArB <br /> Application Accepted By Date "r " `Area ID#F <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> I <br /> Des, i n nspection By pate ' Constructed Well Depth ft <br /> N <br /> COM S I <br /> t yS <br /> ' <br /> It <br /> PE SC Received Check# Amount Date Permit! Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> SO -0013q2197) <br /> EHD 43-02-W WELL PUMP PERMIT <br /> 8/6/04 <br />