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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L. ARTMENT 304 E WEBER. . k: 3"a FL-STOCKTON CA 9520wwjyv) NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRO uz 1 A�e �'] JOB ADDRESS ""r-►tl`i 1 L-We t> CITY/ZIP 777"" eF rs �,/� A C�_ CROSS STREET!- WATA t� �FkW 5 i_ APN 171, PARCEL SIZE I ACC-LAND USE APPLICATION# � r OWNER NAME 12 1-kn] k'F_+t4W J �j00 0f ��(N� --- - PHONE ayyr ry OWNER ADDRESS �AJ`1*L(32- !r'�� -I --44 L `r CITYISTATE/ZIP CIKTO Al Gq, _1 J``79 CONTRACTOR /Vkt-"w-KVF1r j A5-�• PHONE (�9) `124'9�""'2- ` CONTRACTOR ADDR`E/SS,t 1,410 P4, 4 mi e?. CITVISTATEIZIP ST,00czrotJ /cA.']G 5219 SUBCONTRACTORL •��`{��r[ i PHONE 1 SUBCONTRACTOR ADDRESS Loo ` ` �� CITYIS�TATE/ZIP I- -� LICENSE KC-57 ❑C-61 ❑D-09 ❑Other NUMBER �� +�� EXPIRATION DATE Ll ! !dy i ('rEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells #of borings Geotechnical 2 0 ofborings Cl Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 15- ft Excavation ( in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size 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 15' ft Meat Cement(941b bag/5-10gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted ,Grout Placement Method ❑Pumped ❑Free Fall PQ Other T19-IM1S ❑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 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M N! M 41 HOUR ADVANCE NOTICE REQUIRED FOR /INSPECTIONS SIGNED TITLE 1 '-i�1�45T DATE w.-q:i�:YARa LfNE ROA o' O 8�' � to y A10 V ® r raac Q N } [IOC I e.r9t iG a J S{ t _ o21� - " ®M 1---- ---�- ® �'A—c.L N.o' + #'W- IXkA PT 9:,0C-i3Ae G QOAe `I c �° tte aaax J c RS a9 Rg W -gra 'q.t azl Au#6 C-arae pp1 RS. tg4Vpkt 2W see Oat ir:t3AA 6 �' Dk t?#dA'/ q• r-•oar 3x �. � Ra 'I � t N R.& 3k/T,Pgx/43 c:aadlr r1 {� tl h I \b - RS Bk&Pg.1 C-a>•ss, x•:,ssr,.aesa� $ zl c– P Af. Bit if a3}i6e D ��:,L- RTMENT U E O L Y �jt�� Application Accepted ByDateZ- Area �/ Employee ID# G Grout Inspection By Date -I"q ❑ SPECIAL Well Permit Pump inspection By ! Date ❑ WAIVER Received Constructed Well Depth ft COMMENTS , 7:w1"14-7-iZ pyc' sOrv7-E`/cLJ. G.C/�f?1;ba) 4'° 11c"7'j, PE SC Received Check#/ Amount DatePermit/ Invoice# Well ID# Codes Info By Cash Remitted Service Re nest# `?71 571 11�1f5 1 z3 QS EHD 43-02-006 W£LL PUMP PERMET i 1/27/2005