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.aa,n)VELL / PUMP PERMIT %—, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3°o FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE[[PERMIT nCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSr V CITYIZIPyW/�` / 7(� I m a A y //� o CROSS STREET Lr i APN V,( �CJ(,rARCEL SIZE—J.4_ZLAND USE APPLLIC�ATION# / OWNER NAME C�%�;l/CTS �!1!/C�6!^ PHONE �C(j\�� -1,/ -6 7Z�2 y OWNERADDRESS Syntr US ,�I..•�' CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED Use O Domestic/Private ❑irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System VdiRcmm from Owner Contact emeor one u r TYPE OF WORK O New Well O Replacement Well ❑Well Alteration/Modification O Other ❑Monitoring Well(s)_ _ ._#ol'wclis ❑Soil Horing(s)_ soflwnnaa ❑Ocotcchnical #ofbcoa, Wwt-OGServicc Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement O Pump Repair WELL CONSTRUCTION �r Drilling Method O Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool [3 Push Point Cl Other _ J Proposed Well Depth Il lixcavation in diameter ❑Open Boumn ❑(imvel Pack/Gravel Size in diameter c� ❑Conductor Casing in diameter / Conductor Casing Depth A tom'_ Well Casing Diameter in Thwkness/Gaug✓ASTM Sched ❑Steel ❑Plastic ❑Stainless Slee] ❑Other _ Grout Seal Depth R ❑Neat Cement(94 1b hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water r� ❑Bentonite(200/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other Cl Retardant/Accelerator(name) ` PEDESTAL Installed By ❑Driller O 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 B I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TUAT THE WORK %%ILL 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. INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED 1 t� TITLE fie'rl ty�-/v-'- DATE �r^'"�y`S tt l v (• {� U TY A N F 'rill f APARTMENT US ONLY Application Accepted By Date d Area� Employee ID# Grout Inspec on By Date ❑ SPECIAL Well Permit Pump Inspec on B ❑ WAIVER Received Constructed Well Depth '' It COMMENTS _ ItY #/ Ka.• � � µ -'� PE SC Received Check# Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Scrvicc Request# z Sq NL n u S J tq Lt—5e; i WELL PUMP PEW JT 1127/2005 -"