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WELL 1 PUMP PERMIT SCANNED - SAH JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER ArE 3"'FL-STOCKTON CA 942112 - (209)46$-3420 NON-REFUNDABLE PERMIT CALL 204 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Z 'a L•/ � JOB ADDRESS CROSS STREET IGi>✓+ ` APV / /�y/U) /G ..'_.�. PARCELSIZE ONNNER NAME �L C. L ll I_ 7Z'2.7 �.L:,.i/,,/;[{/��//, ,�" 7 _. '7 f(A!� PFIt)NE L4-n�L Imo'/! O\VNEk ADDRESS p�/y��r�/1aL Lr f�'�/�// L J`1Z /V' CITY/STATr1LIP (/-.c-.', '7 /e �ity�7 Fi CONTRACTOR Aid id s �-- I S >L.J f'�-✓ I PHONE P✓4?1?-'C 7!�+ CONTRACTOR ADDRESS � ♦ CITS'lSTA t•ElLIP SUBCONTRACTOR PHo.%E F SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE. -:7 C C-61 C D-09 11 Other NL4MBER Ae ERPIRATIDN DAT£�e%: ^ �1, GEOGRAPHICAL INFORMATIONt Coordinates X Y Township� Range Section 1 INTENDED USF, omesticiPrivate IC irrigation/Agricuitural C Industrial C Water Quality Monitoring C Soil SamplinglCharacterizatinn y C Public Water System If differem from bl— amr yslcm,ame umaa ame o: ane.um er TYPE OF WORK �ew Well C Replacement Well 13 Well AlttrationlModifieali.on C Test Hole C Other ❑ytaniloring IVell(s) number of-d Is ❑Soil Boring(5) numbrT of borings 11 Geotechnical number o(harir. 6 ❑Wel!Destruction C Out-Of-Service Well C Out-Ot-kr,iec Well Renewal C New Pump ❑PumR Replacement C Pump Repair C Cross-Connection Repair WELL CONSTRUCTION — Drilling Method kfgA4ed Rotary ❑Air Rotary O Auger 0 Cable Too[ ❑Push Point C Other Proposed Well Depth a 6t)tl Excavation_J 7 in diameter C Open Bottom MCGrayel Pack f Gra,cl Size m diameter C ConductOr Casing in diameter ! Conductor Casing Depth ft Nell Casing Diameter in Thickness%Gauge.'ASTM Sched &'g� C Steel 'Ndlastic R Stainless Steel C Other Grout Seat Depth Z& ft ❑Neat Cement(94 lb hug 15-10 gal+rarer) C Sand Cement suck mix.i 7 gal uatcr 5Z'Benronite(20%solids) q Manufacturer Spec%solids % Name C Specs on File C Specs Submitted Grout Placement Alethod C Pumped C Free Fall R Other C Retardant r Accelerator(name) PEDESTAL Installed By C Driller PKbmp Contractor C Other ❑Concrete Pedestal Dimensions: Width 11 Length A Thick in C Christy Boz 0 Stoce Pipe PUMP - C Submersible 0 Turbine C Other HP Pump Sec 11 Standing Water Level It WELL DESTRUCTION CJ Open Bottom C Gravel Pack C Uncasted C Other Well Diameter in Total Depth ft Depth to Water R C Casing to be Perforated from ft to It Sealing Material C Neat Cement(94 lb hag/J-10gal nater) C Sand Cement sack rnLx!7 gal water C Bentonite Pellets 1 C Bentonite 20%solids C Manufacturer S ec%solids % Name ' ( ) P 0S on File C Specs Submitted Placement Method C Pumped C Free Fall LI Other C Complete with 4fushrncm Cap fl below grade C Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION' AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IN1IN13TU;NI 24 HOUR ADVANCE NOTICE REQU[RED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED ,J .GC TITLE rt 00 DATE a-2---�,C? l' -11 �-' L Y! h / o ' yy, ri 7,� z.!';3 i - DEPARTMENT USE ONLY' Application.Accepted By L Dale Z. G Area -�"f Employee IDe Grout Inspection _ Date Q SPECIAL Well Permit { Pump Inspection by Date Cl WAIVER Received +f Destruction Inspection B,Y Dale Constructed Well Depth ft COMMENTS '} IPE SC Received �, eeclol Amount Permit! Codes Info By mash Remitted Date Invoice# Well 1D# 4 Service Request# 4 & i f Z Vis.r '3 5a0 } END 43-02-006 �1i�L�-: �_ ��'3S �y/� D �j� W.i7ER WELL PERMIT ii 12/6,2002 Z �