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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL.(2(19)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS N• POPE.ST'A L-ANE: CITY/ZIP LIN DEnI c)5Z3( R <br /> �sc4 ,[ ,tea 05W <br /> CROSS STREET E -6nI—A&LOrA APN 091-3���'f- PARCEL SIZE/2044 LdNY/ 9�f1PP�L�IC�.AyT�IION(#�.P�A�v"tN297 �c <br /> OWNER NAME ✓r-p L&oAzlc L' <br /> 0 PHONE L/�-^'/-�/ r`�J�5452' <br /> 7- <br /> OWNER ADDRESS 000GCCF' <br /> ' L,cvO 40AD CITY/STATE/ZIP /•-, `A•f 9513 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFOR.MATION: Coordinates X Y Township Range Section_ <br /> INTENDED USI ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Udifferent lmm Owner —Sy-in ame _ Contact Nme or Phone Number <br /> TvreOF WDRK ❑New Well ❑Replacement Well ❑Wel l Alteratio ificatlon th r �tionpairchn monitoring Wells) #ofwells ❑Soil Boring(s) #ofical #ofban®ut-Of-Service Well ❑out-Of-Service We al C o ^� <br /> ❑New Pump ❑Pump Replacement ❑pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other r' <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(96 1b bag/5-IO gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft f1� <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT A.ND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COSATION LAWS. V) <br /> I ht A HOUR AD ' 1 CE:NOTICE REQUIRED <br /> JFOR INSP[ECFIONS <br /> SIGNED TITLE ll Vt/�t//�/ DATE ^ —��� <br /> J <br /> d)a7N <br /> N� <br /> �D <br /> 2006 <br /> o couNn <br /> V ENTAD <br /> T ARTtflENT <br /> - <br /> Eb <br /> DEP TMENT U E O <br /> Application <br /> 5pted Date Area Employee ID#Grout l Date 17 ❑ SPECLAL Well Permit <br /> Pump IBy Date /�CJb ❑ WAIVER Received <br /> Constructed Well Depth_ It Q <br /> COMMENTS - C a� C�(j� <br /> UC- <br /> PE SC Receivedheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br />