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✓ WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IITARTMENT 304 E WEBER A*V3RD FL-STOCKTON CA 95202 - (209)46$-3420 NON-REFUNDABLE(PERMIT CALL 209 91533-7697 FOR INSPECTIONS I ,EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS /��-1�� (g � t ) CITY/ZIP L.Jc ,J,,1�., APN7ob-050 'a3 ° CROSS STREET S,` PARCEL SIZE _LAND USE A.P�PLIIC(A�TION# OWNER NAME C�1r r�.IKXhaorn PHONF�� I 'rA' OWNER ADDRESS IL � `/^/J� 4Lj'XA-0r) CITY/STATE/ZIP CA 9 3zn CONTRACTOR /�V7�S ` ,�ee (5(``'I,Q�� 1T f PHON(��-T) CONTRACTOR ADDRESS _ LIS I/V ,�+t[x,\ CITY/STATE/ZIP - SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 A01he, ",U NUMBER1dQ2-737, EXPIRATION DATE 01 0e;, ,�,ax11I GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ 11Y INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industnal ❑Water Quality Monitoring ❑Soil Sampling/Characterization `ly ❑Public Water System Ifdi Berentfmm Owner; ater ystcm ame ontactamcor one um r TYPE OF WORK ❑New Well ❑Replacement Well Cl Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofborings ❑Geotechnical #of bonne` ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑PuTR Replacement ump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger Cl Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 1b bag 15-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20D/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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. M M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED I TITLE /^ DATE Y— UILL A I O U E T ME NT USE ONLY Application Accep[eJ� CSI Y� Date b�7� Area Employee ID# � Groin Inspection By ate ❑ SPECIAL Well Permit Pump Inspection By ate ❑ WAIVER Received Constructed Well Depth R COMMENTSow PE SC Received < Chet Amount Permit/o es Info B Cash RemittedDate Service R uest# Invoice# Well ION 'jw2 \\9 0 END 43-02-006 WELL PUMP PERMIT 1/272005