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r , <br /> SAN JOAQUIN COUNTY I NVIRONMENTAL IIEALTI-1 DEPT '1363 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)463-3420 <br /> 0I..-hM-REFUNDABLE PERMIT CALL_ 209 953-7697 FOR INSPECTIONS 0KNRES I YEAR FROM DAT E ISSUED <br /> 1rn <br /> ,IgG ADDRESS /v . �QLiI.QNt�?D s%- Q L Clr�/cIP s?O kTd.✓ c4ff s ZD Z m <br /> C'ROSS STREET ,Lus� ST�c% iAPN /3`I Z/��aO _PARCEL IZ_ d LAND USEAPPLICATION# H4F <br /> ,J Cn <br /> OWNER f�1ANIE V AIyAF t SZ•T /'AA.// i'�IIONE n <br /> L w 64 <br /> OwNER."DDRESS Go L1 ` A LIQ O1'A S�, CITY/STATE/Zip s/DG�t�'Ii✓ /75'40?' <br /> G5'ZO?' <br /> i::ONTRACTOR bin F S9a 2Z: �AP[IONE /�i. ��� IyIlir <br /> r.;ONTRACTORADDRESS 33s 7 F- Te6felLD R�. CITY/STATC(ZIP 04PegO L-P&J,✓A L4 7Jr <br /> f�u <br /> SUSCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE 57 0 C-610 D-09 ❑ Other NUMBER 94/ L'z Z -7 EXPIRATION DX.E <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Pi D Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring S.QiI Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name on ac' amo or one um er <br /> ","(PE OF MIORK 0 New Wall 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) 4 of wells 0 Soil Boring(s) #of borings geotechnical Qi 1P of borings <br /> ❑ Out-Of Service Well ❑ OUt-Of-Seivice Well Renewal ❑ Cross-Coni ciion Repair J - /ao <br /> 0 New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well asing <br /> WELL CONSTRUCTION <br /> Oriffing <br /> ONSTRUC ION <br /> h'iliing Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well DepthSO-/00 f it Ercavatioii in diameter ❑ Open Bottom ❑ Gravel PacldGravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth Ift <br /> 'Weil Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth$-O -/Oe ti Vueat Cement(94/b bag/5-10 fal water) ❑ Sand Cement sackmix/7 gal water <br /> ❑ Bentonite(20%solids) D Other _ <br /> Grols4:Placement Method ❑ Pumped ❑ Free Fall 0 Other / A-6M-7r D Retardant/Accelerator(name) <br /> Pr--DESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 0 Submersible❑ Turbine 0 Other HP Pump Set ft -Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNT`( ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CAI_IFOs.NIA CONTRACTORS STATE LICENSE BOARD AND THAT.I AM IN COMPLIANCE WITH ALL <br /> '1 C;Pdd ERS COMPF_NSAT101\1 LAWS. <br /> MINIMUMR#HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED 1 ITLC- 6'dJ.'L'0/( c/V L`=wZ DATE <br /> SA 4 JAUI ON <br /> -- — IR N AE 4T <br /> H DEI <br /> DE ARTMENT S - ONLY kf/�� <br /> Application Accepted By• ` Date Arca_L <br /> ' Employee ID# <br /> Grout Inspection By Date P-Ct'AL W811 Permit <br /> Pump Inspection By Date ,-/ VVAIVEP. (Received <br /> Soil Boring inspection By Date�[ Constl ucied Well D d. <br /> COMMEI�ITS o —` Fit <br /> PE SC, Received Checld""/ Amount Permit <br /> Codes ln•fo i3v Cash y <e.raifted bate Service Request Invoice i Well ID# <br /> �-oH� vJPD�3°I 50�0 <br /> EVID 43-06 WELL/PUMP PERMIT <br /> s10<U06 <br /> `a <br />