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- WELL 1 PUMP PERMIT <br /> i N JOAQUIN COUNTY ENviRONMENTAL .�TH DEPARTMENT 304 E WEBER AYE a-. �-STOCKTON CA 95202 -(209)468-3420 <br /> i.: <br /> NON-REFUNDABLE PERMIT- - -`CALL 209 453-7697 FOR.INSPECTIONS - EXPIRES l YEAR FROM DATE ISSUED <br /> i Job ADDteEss 1 <br /> V rZrd J r n (J�[y a W�y/� /1 CITY/ZIP 4 q J ?fi o . <br /> CROs STREET ` 0 APN 1-i C!O Gl/' 7. PARCEL SFZEjaaaWND USE APR.ICATION# A <br /> -,� <br /> 1 O9VNER NAME-�' E-�-cLf-K-��' I L Cr .Y•I r. ---� PHONE - <br /> OWNER ADDRESS C17v157ATF/ZIP <br /> CONTRACTOR - C(?f��Ly �!`1'1 1 GG I/rl`(.S ��`,�� �/�� /PHONE <br /> CONTRACTOR ADDRESS <br /> I � Crry/STATEIZIP <br /> SUBCONTRACTOR GrJlPHuO�NE�1rc7n�ZSC) <br /> '31-3-5100 <br /> • •- -CIrY1STA7FIZ[P �Fir(h-� <br /> I SUBCONTRACTOR ADDRESS - .. .. <br /> LICENSE' C-57 13 C-61 ❑D=09'1"0 Othet '' - NUMBER"_ 1' 5 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: COaI'dlnatab,'X 63y 3321'.: Y_Z}. T-ITj Township Range Seetion w <br /> INrENDUD Use ❑DolnesticlPrivate ❑IrrigntioiJAgricultural ❑:Industrial ❑Water Quality Monitoring Soil Sampting/Characterization <br /> j ❑Public Water Syystem -3 <br /> Ifd1fNaent from OrTlcr: ater yuma rme unmet am or <br /> TYPE P W RK O New Weil-. ❑Rcplacernenr.Well ❑Well Alteration/Modificaiion ,, ❑Other <br /> k oFboringi .. - " <br /> ❑Monitoring Wel](s) #o_Fwdls (3Soil.Boria - <br /> .dbm.r <br /> g(s) �,�Geatechnical <br /> ❑Out-Of-Service Well 0 Out-Of-Service Wel!;Renewal ❑Cross-Connection Repair <br /> ❑New Pume ❑Pump Replacement - ❑Pump Repair <br /> WHLLCONSTiet) TON !' <br /> DrItung Method O Mud Rotary -❑Air Rotary ❑AugcT 'E]Coble Tool - )&,;Push Point [3 Other' <br /> A I - <br /> Proposed Well Depth 'ft Fatcavation .in diameter ❑Open Bottom_ ❑Gravel Pack!Gravel Sire in diameter Q <br /> 0 Conductor Casing in diameter—/ Conductor Casing Depth ft <br /> ! Weil Casing Diameter in Thicknes�.!F.augelASTM SCh '' •❑Steel ❑'Plastic ❑Stainless Steel ❑Other <br /> Grout Sen! Depth ft JW.,Cf-(i4!b bag 1 S-10ga1 warm) ❑Sand Cement sack mir 17 gal water <br /> ❑Bentonite(20%stilitisjr——iTanufactum Spec%solids % Name 0 Specs on File ❑Spas Submitted <br /> I Croot Placement Method ped--'l eFree Fall-- ❑Other ❑Retardant/Accelerator(name) - <br /> i <br /> iftDVSTAt, Installed By ❑Drilter O Pump Contractor ❑ Other }p <br /> ❑Concrete Pedestal Dimensions:Width ft Length . A Thick" in ❑Christy Box O Stove Pipe <br /> I ' <br /> PUMP `- "' ' ❑Submersible ❑Turbine '❑Other - HP w'Pump SN '- Ift Standing Water Level'- '" it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILLBE DONE IN ACCORDANCE WITH SAN <br /> l JOAQUIN COUNTY ORDINANCES,STATE LAWS AND RULES AND REGULATIONS. ,1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS `] <br /> I CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM-IN COMPLIANCE WITH ALL T <br /> WORKERS COMPENSATION LAWS. <br /> �MINIMUrg,24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �! . <br /> SIGNED P' TrrLE /�SS�C. 1. - -D �]/qATE •I Z-A/1t7 <br /> 1 <br /> Ell <br /> , <br /> PAYMENT <br /> -RECE NED <br /> 1 <br /> S£p 6 2007 <br /> w <br /> SAN JOA IN COUNTY <br /> ENVIR R' k {. emu i ENTH MEtdMENT <br /> a,; <br /> m <br /> HTAL <br /> FlHf <br /> r ` <br /> . AEPARTM,ENT USE /QNL�Y.. <br /> Application Accepted 1B, <br /> y .y LI- 7 Area Employee 1D# '75-79 <br /> / <br /> - - Grout Inspectisu B c. �' �� 13 SPECIAL Well Permit ! q y <br /> I{ Pump lnapection By Date - �r'-''' ❑ WAIVER Received <br /> I <br /> { Constructed Well D th <br /> COMMENTS <br /> PE SC Received Chechti! Amount Date 'Permlt!- Invoice# Well IDN <br /> Codes Info B Remitted Service Ae uest# <br /> S��iz D Gb - 3aa• � � <br /> I EHD 43-g2-0Ob WELLPLIMPPERMIT <br /> TEF tmnsos <br />