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WELL/PUMP PERMIT SAN JOAQVIIJ COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FoR INSPF.CI lO\S EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS. S7, 4u-41; OU CITY/ZIP II Il.7 "'� APN CROSS STREET ��'7QS�Y,/�rj-�•S�{`\/[T'� - / y• 7 LEAPPIICATION{ OWNER NAME IL / ^�TJ S A44YSV, PHONEJ �' OWNERADDRESS � LL .! T CITY/STATE/ZIP CONTRACTORf��,,f� (�PHONE-f CONTRACTOR ADDRESS I�I I.PNS rte(r• CM/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/SSTATEIZIP �7 LICENSE )C-57 ❑C-61 ❑D-09 ❑Other NUMBER�a�7 7 EXPIRATION DATE 2�/ GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rangt Section INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ' ❑Soil Sampling/Characterization ❑Public Water System IfdifTeremfmm Owner: ser ysrem ame Coruact Namew Phone Nuffiber TYPE OF WORK( dew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #ofwells ❑Soil Bonng(s) sufborinas ❑Geotechnical sofbonngs ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair [V ❑New Pump O Pump Replacement ❑Pump Repair WELL CONSTRUCTION ^ Drilling Method kVI:LAud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other V Ir Proposed Well Depth,22 7 ft Excavation_l in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter ❑Conducto ng in diameter / Conductor sC'aasing Depth ft Well Casing Diameter m Thickoess/Gauge/ASTM Sched [ ❑Steel ¢Mastic ❑Stainless Steel ❑Other Grout Seal Depth If it ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water O'Bentonite(20%solids) ❑Manufacturer Spec%solids % Name G Specs on file ❑Specs Submitted ` Grout Placement Method CR�!pmped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller mp Contractor ❑ Other ❑Concrete Pedestal Dimemions:Width ft Length R Thick in ❑Christy Bos ❑Stove Pipe v I r PUMP ❑Submersible ❑Turbine ❑Other IIP Pump Set ft Standing Water Level R 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN / JOAQUIN 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 IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IM wM INIMLr 24 HOUR ADVANCE NOTICEa'�RE91,IIR^ED FOR INSPECTIONS SIGNED I)L*(_ / lrr1�1�C L:. TITLE `)Yv I/IK✓I DATE' V 16 b 7 r / l v E RTMENT tU�S ;71, - - - - Application Accepted By to a Arca Employee]D#Grout Inspection By � Date ❑ SPECIAL WEII Permit Pump Inspection By Date ❑ WAIVER Received Constructed Well Depth ft COMMENTS PE SC Received Checld/ AmountDalt Permit/ Invoice# Well ID# Codes Info as Remitted Servi SE kequest# /8 / 2- uPd D 5? EHD I3-02.OD6 WELL PUMP PERMIT 1212005