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WELL/PUMP PERMIT <br /> SAN JOAQUUi COUNTY ENVIRONMENTAL,LTH DEPARTMENT 304 E WEBER AVE 9%,.,,STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT t•,M.L(2(34195.3'69'FOR INSPFCTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ✓' Y 1 arGl1✓\Gl oo-/ CITYZIP <br /> 11 2 A.C.LAND USE APPLICATION# <br /> CROSS STREET �/fit O✓� 5t Ir�"� APN PARCEL SIZE <br /> OWNER NAME 17 Y lQ. cc, l PHONE7 -6IISS �A <br /> OWNER ADDRESS O�G CITY/STATEIZIP Mour-+O'iyl (k DtYIGVI (Xt <br /> CONTRACTOR l-7�I _�� 1�J 1U`G�.�C-S ,J I /'(Q ^PAHONE LO` 5-11—'t^���� <br /> CONTRACTORADDREss Lin <br /> �--C�hF—Ca�V\� 11VAO4F�-S-tU) v„ CITY/STATEIZIP r,l 95k95t00. (2-(A q <br /> SUBCONTRACTOR Wooc�,y�xC�rA .4/YT� ` `e�' PHONE <br /> I ,70 / �1^—'tit-4430 LI <br /> SUBCONTRACTOR ADDRESS ?0 CITY/STATFJZIP R 1� �/1 S'�L 1X1 <br /> LICENSEC-57 E3 C-61 [3D-09 C3Other NurABER D D'l EXPIRATION DATE <br /> GEOGRAPHICALINFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Moil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdiff tf..0-- Wafer System Name Cuotart Nameor Ph one Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #Of wells Soil Boring(s) #of bornss 5 ❑Geotechnical #of b011sa <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION / <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool Point ❑Other <br /> Proposed Well Depth 55 it Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in(fiameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth S It ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sock 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 ftThick in Cl Christy Boz ❑Stove Pipe <br /> PGMP ❑Submersible ❑Turbine ❑Other HP Pump Set It 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 /> 4 7Yf bli`1i 24 F1{3"+),IC�R}'S'4N{;1;:ti4)'l I[:J:i;1.4�E'1111'I3 X'E}'1a f�fSYF:{:f7.{3N i ^ <br /> SIGNED TITLE DATE II J(0, <br /> EPA TMENT USE ONLY <br /> Application Accepted By / Date 0✓ 17- 7(�05 Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed 1 Dep ft ) <br /> C MME S O W !J r <br /> CI <br /> PE Received Checldi/ Amount to <br /> PermW Irrvolee# Well IDN <br /> `C <br /> Codes Info B Cash Remitted Service Re uest# <br /> 3501 qq Li -" �`1 o (� a <br /> 3503 <br /> 's0r �� &9 <br /> EIrD 43-02.006 C <br /> 1127/2005 WELL PUMP PERMrr <br />