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i <br /> CO <br /> WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL.(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEp 1 <br /> tsJOB ADDRESS 1 / W S W JAI{kyJ 243-300-0110 Z+o SP,eq CITY/ZIP 4-41,—P <br /> + 213-7430 <br /> ', CROSS STREET 5[C69CL�L I Cd�Ir..� Ctet APN 21;-7.710-Q Z, PARCEL SIZE LAND USE APPLICATION# A <br /> f 7.13-A40-01 ,0-A-to3,0cl y � <br /> OWNER NAME Rvtr =gla��tS 91"3 J- 4M-12 PHONE 1 <br /> OWNERADDRESS j �']� 5_ qr �qr, Ro( _ CITY/STATE/ZIP ( 1 co 93a.,.___ i <br /> CONTRACTORIBJ 6._�Q �[ PHONE�Zro q18 3 Sld6�0 �� . <br /> ryry��pQ J �y r I <br /> CONTRACTOR ADDRESS lrl7V N- �� � R I IIOr. CITY/STATE/ZIP --rmc,i <br /> �j r + I <br /> SUBCONTRACTOR TGLC[ T'C C D%-tCA <br /> 11 V�q ,//AJ� PHONE ,.I, •7 <br /> SUBCONTRACTOR ADDRESS !q Tos Sa,-. !'T <br /> �f 10 ye- CITYISTATE/ZIP .Snt aX659- <br /> LICENSE c- <br /> 57 11C-61 ❑D-09 ❑Other NUMBER �q9 381 EXPIRATION DATE <br /> i <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township RangeSection i <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Wa o itoI [i g/Char ' anon <br /> l <br /> ❑Public Water System , <br /> If different from Owner: Water System ame VfrlIkNarpe prone r <br /> w <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modificationhb ma�R%ye 84 <br /> t!of borings " gs <br /> ❑Monitoring Well(s) #of wells R[5oil Boring(s) ��'�.O �/ I' p ('� of h tca + <br /> ❑Well Destruction ❑Out-Of-Service Well C]��t-Ary VJE=17'R��� ected <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair so s Rt^ t t <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary %Auger ❑Cable Too] ❑Push Point ❑Other <br /> Proposed Well Depth /5-W ft Excavation !q in diameter ❑Open Bottom ❑Gravel Pack/Gravel'Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Stec] ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft XNeat Cement(941b bag/5-10 gal water) ❑Sand Cement .tack mix 17 gal water 1 <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name C]Specs on File ❑Specs Submitted C_ <br /> Grout Placement Method ❑Pumped J&Free Fall Of Other Te-Tc -n�Edl 13 Retardant/Accelerator(name) } <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other t <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft ' <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 I AM IN COMPLIANCE WITH ALL k <br /> WORKERS COMPENSATION LAWS. I <br /> M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE 4V-"g0r 7-ed p✓7 DATE /Z <br /> 1 71 <br /> Ar <br /> OL <br /> I PAY Ej 41 <br /> ~r <br /> C V <br /> ' � r `=�;.��.` • . ��..�-„� wry <br /> NV <br /> etVM ke <br /> r- I <br /> Ir- <br /> DEPARTMENT . <br /> ter` <br /> USE ONLY <br /> - .—'-"_- ,ter, ; <br />�. Application Accepted By Date Z_3/ <br /> 3 �S' Area Employee ID# <br /> Grout Inspection By Date d& ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received i <br /> I <br /> Destruction Inspec;on By Date Constructed Well Depth ft <br /> CO ENTS i� <br /> PE SC Received Check# Amount Date Permitl Invoice# WellID# <br /> Codes Info BV --c—ash Remitted Service Request# <br /> y 3. r 0 7Z6-- too.nJ3-J a L4 l 3 11 <br /> -� EHD43-02-006 '�GlLtr� Q �lr�"Y�-' U� `C�'1'�JC:%� WELL PUMP PERMIT <br /> 916 04 <br />