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i l✓ � WELL / PUMP PERMIT 54SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH bl!!FARTMENT/ 304 E WEBERr./L/ 3-FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL �(2/0r9y 953-71697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 A Z\y • (Q, 1\ \ W�7 VI CITY/ZIPS 5 Z�5 m O CROSS STREET��`VA• APN ,3,— � �6� PARCEL SIZE LAND USE APPLICATION# 7 H OWNERNAME YL/�1j�j(�j)t�r ,\/`tC��`t��y\� � PHO1NEEr�� OWNER ADDRESS /y25` 5 �Jb-r(' l-S• ioce,, r0�r�� CITYISTATE/ZIP � k50r t t Q+ gr5 p(p30 CONTRACTOR li.lM` GCG e�`•" ' �L��,,4..{,�1i�` ,�r\�/t�tr�'I�,,,, rIy PHONE tsQ _G zZ N� CONTRACTOR ADDRESS 1J,,�✓r�/ ) `Y�t'�oISI/l OA (N JP,+Ea t�Lky.;� JItL CITY/STATE/ZIP ' SUBCONTRACTOR 'Ero(Y}ynI/�J1 t� tmIt��sr IDnC • y� /IT _cPHO—N/Eq)6-3(PZ-5sy1 ,Y70y 0 SUBCONTRACTOR ADDRESS Q C {O �J W(P7P.S5 1 a r K 4�r/ S (-rt/QC•ITMY/STATE/ZIP �—�-T04 Cil Q LICENSE C-57 ❑C-61 ❑D-09 qq❑rr Other / !( NUMBER U p o�r�� EXPIRATION DATE_3 1 GGA' o C GEOGRAPHICAL INFORMATION: Coordinates X31!53r0�•IvV Y \ZA• Z--VILA-°utl Township Range Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Chamcteriwion ❑Public Water System If,iffereat from er: Water SysFm ame Coowt Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Wells) #of wells ❑Soil Boring(s) #of bonop `I Geotechnical k ofborinpe 5 ❑OutOfService Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Plump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 35 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_Gqiffin Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other ( ^ Grout Seal Dye/pth a 5 ft *cat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water v l la-Beatewte{20%mkds) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted ✓� Grout Placement//Method ❑Pumped ❑Free Fall ❑Other ks 922a ❑Retardant/Accelerator(name) O PEDESTALnstalled By ❑Driller [3Pump Contractor 13Other ` ') I tJ Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level It 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CSl SIGNED TITLE (,Jl7t/ DATE ( L0340 crg �IEA sl 5 A0 aAtoN E 1 N E H D ARTMENT U E O LY Application Accepted By Date �6 Area Employee ID# Grout Inspection By Date U ❑ SPECIAL Well Permit ' Pump Inspection By Date ❑ WAIVER Received Constructed Well Depth 1 ft COMMENTS C�Iti c.J 141 3L o�Ft-= k./ d'ed PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B s Remitted Service R uest# i L 00 4 9 Lf 4 Z END 4342-006 Inl/2005 WELL PUMP PERMIT