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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENT TH DEPARTMENT 304 E WEBER AvE 3e TOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT /�—� ,I� CI.4L.I,(209)353%G9%mit INSPECT'[e:NS EX*RE IS/I YEAR FROM DATE ISSUED <br /> JOB ADDRESS LIZ ll�.- G I arG`�✓1 c1 0��/ CITY/ZIP t <br /> CROSS STREET ()A\O t^ ✓t f C+L� APN PARCEL SIZE Z FFC LAND USE APPLICATION N <br /> AYiA <br /> O NERAME __v I to P.O'M 7- <br /> y011 <br /> 75j--61 <br /> ��O.�OGJ <br /> OWNER ADDRESS p CITWSTATEIZIP Ol)11l0.1✓I ISS/+Int <br /> r�DWIG 4'1 l ,7't <br /> CONTRACTOR E-}-T—, i✓l-ss'o1u`ate^�t5 f /�y7 PIoNE Zo9 S1q-�ZZZ-I <br /> CONTRACTORADDREss L11-7 Lo'�W_rQtT� Y1 r LOCAQ..S�V fT C.TY/STATFJLR M od.a—./sfoi L' K / <br /> SUBCONTRACTOR Woo t�,�Atrt� .V r,L\i/`c} PHONE__ y 0-7 -25-1L�4 <br /> -—t 3Q() <br /> SUBCONTRACTOR ADDRESS?O 30k —5 CITY/STATE/ZIP R10 UR S-VA , lXT <br /> LICENSE C-57 ❑C-61 O D-09 ❑Other NUMBER D Oj ExrtRATION DATE <br /> GEOGRAPBICALINFORMATtON: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural O Industrial ❑Water Quality Monitoring il Sampling/Characterization <br /> O Public Water System <br /> IfdiQ Ifiom Own—. Water System Ns C-ts Nw Phone Number <br /> TYPE OF WORK O New Well ❑Replacement Well 0 Well Alteration/Modification O Other <br /> O Monitoring We6(s) N of wells Soil Bormg(S)Gt4CD�OQ._p°f b01nse 5 ❑Geotechnical k°f b0"s` <br /> O Out-Of-Service Well O Out-Of-Service Well Renewal O Cross-Connection Repair <br /> 0 New Pump O Purrrp Replacement t O Punip Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tod Push Point IJ Other <br /> Proposed W eD Depth 55 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic O Stainless Steel ❑Other <br /> Grout Seal Depth S5- ft ❑Neat Cement(94 lb bag/5-10gal water) O Sand Cement sack mtx/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufachaer Spec%solids_% Name ❑Specs on File O Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor O Other <br /> ❑Concrete Pedestal Dimenslonr.Width ft Length ftThick in ❑Cbrlsty Box ❑Stove Pipe <br /> PRm O Submersible ❑Turbine ❑OtherHP Pump Set ft Stan&ng 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 /> A :'f:Vf(:`1I24HOT,N-,41WANCP,NO']TICEREQ LIIUJ)FOR INSPki.'f1'mm <br /> SIGNED TITLE DATE i <br /> N� <br /> VED <br /> 2005 <br /> IN COUNT( <br /> MENTAL <br /> DI PARTMENT <br /> ———4T7— 1 1171 <br /> EPA TMENT USE ONL,�Y��,.RRc� <br /> Application Accepted By J Date /0 V ?WS Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed 1 Dep ft ) <br /> CJQMME S O try r <br /> CI <br /> PE Ae Received Checldl/ Amount Perm1U <br /> Codes Info Ally Cash Remitted Date Service Re uesf# Invoice# Well ID# <br /> 351 8� 12P - �`( i07/K <br /> 'SO1 =—Al <br /> EM 43.02-006 <br /> WELL PUMP PERMIT <br /> mm/Zcos <br />