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LL WELL/PUMP PERMIT SAN JOAQUIN COUNTY£NVIRONMENTAL._:.LTH DEPARTMENT 344E WEBER AVE c STOCKTON CA 95202-(209)46&3420 NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS - EXPIRES 1-YEAR FROM DATE ISSUED i 2 ��11_ m JOaADDRESS - - 1 J• !--s– -r nor' fI✓v-- — _ C.,Z,, w L.4-f rgp - a �J e CROSS STREET L.�r1,rr APN I9S+ZQO•G)2-PARC ELSIZE "✓/LAND USE APPLICATION OWNER NAME -. �I.- I�'t GC.K— -1<"L 7•'jE,- 'I I:L'7+•, C.-rD- 1"T-A PHONE I OWNER ADDRESS r ,�] CITY/STATFIL[P 7 CONTRACTOR C n J,/ ��r 1 , Te,--X(/i1 A 104'r i t1Y yTn c- _ ___ PHONE �'t�Z 7�.. Q S f y ~ CONTRACTOR'... fF/` -1 �f �- - CrrY1SrATF/ZIP '315 7 q SUBCONTRACTOR �.tT1ry IVr. � 'r/ry�La _ yPiton'31 S 3IJ 59,00 SUBCONTRACTOR ADDRESS +' O t✓G'. r't+i .' .,CCI ITy//ST/AnTE//ZIP/`!F/I 1 q GY cLk 1 f 9:�j� LICENSE �57 ❑C-61 [31).6- -0 Other s'' f- - �7NUMBER 3f`�GC,'IL` 5 EXPIRATION DATE CT.ocRAPHtCAL INFORMATION: Coordlnatp-1X •�i3�, Y .2 t� Township Range . Section - KKTT.NDEOUSE ODomestie/PrNatcr_ �Dlrrigation/Agricultusal ,;❑,Industrial , 0Water QualityMonitoring 'Soil Sampling/Charaetetization ❑Public Water System Ifdiflernn fiem Owner ata byalm Nam ontact mneor ne - TYPE OA WORK O New Well ❑Replacement Wei] O Well Alteration/Modification O Other - b of borings M of borings O Monitoring Wap{s) #of welts Q Soil.Eoring(s) �GeMechnical Cl Out-0f7Service.Well sO Out-0f-Service Well Renewal ❑Cross-Connection Repair y O New Pump 0 Pump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Metiod Oud MRotary -O Air Rotary ❑Auggr _" `❑Cab4e Topl '06ush:Point ❑Odser, V�-{V h, V4 Proposed Well Depth R Excavation '. in diameter, ,.0 Open Bottom - 0 Gravel Pack!Gravel Size - in diameter r O Conductor Casing in diameter I Conductor Casing Depth .. @ ftti Well Casing Diameter in T'hickneWGaugeJASTM Sched 0 Steel- 0 Plastic ❑Stainless Steel ❑Other•` e Grout Seal Depth ft •Neat Cement(94 1h bag 15-10 gal water) O Sand Cement crack mix 17 01 Water ❑Bentonite(200A solids) O Manufacturer Spec%solids_% Name O Specs on File O Specs Submitted Grout Placement Method -liputnped Xfree Fall O Other ❑Retardani/Accelerator(name) MPESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other O Concrete Pedestal Dimensions:Width "ft Length ft Thick in O Christy Box 0 Stove Pipe e O Submersible ❑Turbine ❑Other NP ' 'Pump Set - fi Standing Water Level ft D - I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN' IOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED.LICENSE IS CURRENT AND ACTIVE-WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM[N COMPLIANCE WITH-All WORKERS COMPENSATION LAWS, - r /�!J MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS L� .� SIGNED / �.l��l�' � TrrLE z4 Ste, d C17 ,, ��'Cn ., DATE•t 1I - ___.. ` w tN M pp, D NO Ew Zr SEP 2 2007 # a°AQ 1� L .t SAFNv% Mmµ DEPA.RT_M,EN_T U E.,OlNLL7Y Application Accepted By ... Date Q 2GL O / Area Employee 1D# �'�2 . Groutlnspcction-By' -•-Date. 6 ❑t, SPECIAL Well,Permit- Pump Inspection By ,••r .Dole - `i.0 -i 0: WAIVER Received. - Constructed Well Depth R , COMMENTS�47 15s�, �-S�r.t�..� 1. �X.e�fli� ;t,/ Lrr�.i /zswJ..c.t. PE SC Received /Checkv J Remitted Amount Permit! � Date Ill well Welllbq Coda Info 8 ---C I-es q Service Request* '�. � /eS0 6 t7 80• 1 a •S 2 I(50 END 47-0-006 WELL PUMP PERMIT... Imrsoal