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VVELL/PUM P PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT '1868 East i-lazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> i'IUPI-REFUNDABLE PERMIT CAL!_ 209 953-7697 FOR 114SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> W <br /> CITY21P 7V13oqi swc�as Pd,JOB HDDRESS . <br /> CROSSSSTREETU41 I-ek kI"' APM Z(444 PARCEL SIZE/`'5 <br /> LAND USE A[P'PLICATION#y <br /> OWfUER T-IANIE F I,+��� .y^� (41 -4-4-- <br /> � I f PHONE -^'/0N` s Iyn <br /> OWNER:'.DDRESS y►4 00 a l..A�-- CITY/STATE/ZIP AS IN �b / CT `S? <br /> CONTRACTOR Mat{I t is b"W)Knj J=INC. - PHONE S I �} <br /> COMTRACTOR ADDRESS_L_� IbcrS kA CITYISTATE/ZIP ,r 100"'S �� CK <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 'CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-81 0 D-09 ❑Other NUMBER "An2C_ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DOmestic/PrIvate 0 Inigatlon/Agricultural 0 Industrial D Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner, water System Name on ac eme or Phone Number <br /> TYPE OF WORK New Well 0 Replacement Well ❑Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(S) a or borings 0 Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> SMELL CONSTRUCTION <br /> Drilling rJiethodXMud Rotary 0 Air Rotary 0 Auger ❑Cfble Tool ❑Push Point 0 Other <br /> Proposed Well Depth *2$00 ft Excavatlon I'A- In diameter ❑Open Bottom )lMravel Pack/Gravel Size in diameter <br /> 0 Conduct�r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter b _1n Thickness/Gauge/ASTM Sched�6 O ❑Steel Xlastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth_ ft 0 Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cament sack m/x/7 gal water <br /> )Oento (20%solids) 0 Other <br /> Grout Placement Method umped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick In 0 Christy Box ❑Stove Pipe <br /> PUMP 0 SubmersibleO Turbine 0 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE 140TICE//RR\EQ��U��IRED FOR INSPECTIONS 9 Q <br /> SIGNED TITLE f�rU►4.�/ DATE <br /> 91/1 1 <br /> A <br /> ni FA <br /> UI C UNTY <br /> IR N <br /> EPARTMENT U E IIlM�J <br /> Application Accepted By / Date V � Area a Employee ID# lt�f�If^ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth <br /> /JO ft <br /> COMMENTS Serfs L �.0I �f�l/6 r 04&V&:x �(AF��Ai/A 7/11 Z (f' <br /> PE SCRecoived Checic#/ Amount Data Permit/ Invoice# Well ID# <br /> Codes Imo B Cash Remitted Service Reguest# <br /> � '3 210 ISP <br /> 2 � <br /> EHD 43-06 W ELL/PUMP PERMIT <br /> =4/06 <br />