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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dom-..NtMENT 304 E WEBER,- f3R°FL-STOCKTON CA 95202 - (289)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> G _Z Z� <br /> t <br /> JOB ADDRESS ��s•Se���an, .rot CITY/ZIP eSLC7;.tC31'� > <br /> C <br /> CROSS STREET I` 1 WY Y� APN?f4!5; j�A-64�PARCEL SIZELAND USE APPLI tED <br /> JJ � 1 <br /> OWNER NAME LLCJ-r r V1 to J e I.�J Xe r - - PHON <br /> F �7 - � rirr�,I \ j Q <br /> OWNER ADDRESS ? 41 j�� . —_]e>an i CITYISTATE/ZIP C➢LlC ] l�J �Z=/�t <br /> CONTRACTOR PHON[1`� /��� <br /> ' CONTRACTOR ADDRESS c,J Y-1 CITY/STATE/ZIP T r C� 9-5,3-Lia 5s 3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other __ NUMBER l©t oZ-73 Z EXPIRATION DATE 1A 1G! <br /> , <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township RangeSection <br /> INTENDED USE Domestic/Private ❑Inigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Vdifferem from Owner: Water System Name Contact Name or Phone Number <br /> k. <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> I <br /> ❑Monitoring Well ❑ <br /> Well(s) #of wells Soil Boringk of borings <br /> Boring(s) ❑Geotechnical N of borings <br /> ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump 7gPUmpReplacement ❑Pump Repair <br /> WELL CONSTRUCTLON <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 0 Other <br /> { Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> + ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft O Neat Cement(94 lh hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ' ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑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 r-3 Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> I WORKERS COMPENSATION LAWS. <br /> MIN M 2 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE —� DATE <br /> 3 <br /> I <br /> i <br /> r <br /> i <br /> I <br /> hF4f t,1, `J ''iEf'7n t I <br /> M-YT <br /> DEP R T M E N T USE ONLY <br /> '!� /, <br /> ,Application Accepted B���•� Date- � - Arca- Employee II3#. � <br /> Grout Inspection By Date 54 ❑ SPECIAL Well Permit <br /> A <br /> Pump Inspection f�,. Date ❑ WAIVER Received <br /> T <br /> Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Chec51 Amount Date Permit/ Invoice# well JIM <br /> Codes Info By --Cs$h Remitted Service Request# <br /> 14r , <br /> END <br /> t <br /> END 43-02-006 _ q <br /> 1n712005v '- i <br />