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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENV IRON MENTAL HEA LTH DEPARTMENT 304 E WEBER AVE 3•'FL-STOCKTON CA 95202- (209)465.3420 <br /> • NON-REFUNDABLE PERNEIT CALL. 209 953-7697 F'OR INSPF,CI'IONS EXPIRES 1 YEAR FROM DATE ISSUED N <br /> nY <br /> JOB ADDRESS <br /> 4,Jy 12-Z---, c2-Z---, c �`/�C,' 1`q� I � CET'Y21P 2 'I 1/"1n0 Rk"i4PN 07-3 I SJ 1 y G e <br /> • CROSS SPARCEL SIZE LAND USE APPLICATION# <br /> TREET <br /> a SU.0 2-4L <br /> OWNER NAME M I I_J-- I ' PHONE i <br /> CITY/STATE/LIP <br /> OWNER ADDRESS <br /> t45j'-1+Ai FJCIR� lrtLS� IN6 PHONE I �l°� Z�L� C�/6� <br /> � <br /> CONTRACTOR ADDRESS ' 0 0 �4 A 1 W:. A Q S 1.1' ( L (f-'" CRY/STATE1ZI7 K L�f�Igit CA � 16- 1 <br /> SUBCONTRACTOR 1C,r J,41�.,L' '1 ^+( 1�'PHONE J 16 3 <br /> SUBCONTRACTOR ADDRESS 3 1`\ VY t�S I C'r I�1 111_0(r A s CrrYY/STATF/L� w�`/ <br /> LICENSE -57 ❑C-61 O D-09 ❑Other NUMBER 1 V EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ❑DomestiC/Private ❑Irrigation/Agrimliural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characterization <br /> ❑Public Water System a <br /> If diff—I 1—Owner .- A— .mc mua me s• <br /> TYPE OF WORK ❑New Well ❑Replacement Well O Well Alteration/Modification ❑Other M of boring <br /> M of bonnps O Geotechnical \`' <br /> ❑Monitoring Well(s) M of wells Soil Boring(s) r J <br /> O Out-Of-Service Well ❑Out-Of.Service Well Renewal ❑Cross-Connection Repair \N <br /> O New Pum ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION 1, <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth �2S A Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor C ing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter LOT! Thickne���ss/l.uge/ASTM Sched ❑steel ❑Plastic ❑Stainless Steel ❑Other . <br /> Grout Snl Depth 11 Neat Cement(94Ib bag .540 ga!warerJ Ct-�^'�❑Sand Cement sack mix/7 gal water �j <br /> 1❑._ '?&(LA.4-'t-`I'-P"t�' ❑S on File ❑Specs Submitted 11 <br /> ❑Bentonite(20%solids) Manufacturer Spec%solids % Name LYS <br /> "7)6'x Pe <br /> C <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> c.0 `� <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other . <br /> ft Thick in ❑Christy Box ❑St—e <br /> ❑Concrete Pedestal Dimensions:Width ft Length Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R Standine Water Level <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 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 /> � � M111:' A•I II M11 2A HOUR ADVANCE.NOTICE RF;QIIIRF;I)FOR <br /> IN'SPF;C'TIONS <br /> 'T I .w i. TITLE <br /> DATE B <br /> SIGNED_y <br /> PAYMENT <br /> RE_CENED <br /> JUL 2 6 200 <br /> AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> D E P A R T M ENT U -E ONLY L� <br /> Application Accepted By4'�-- Date Z�l s Area Employee IDM 5 3 q <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> Permit/ IovoiceM Well IDM <br /> Codes Info B Cash Remiued <br /> Date Service R nest <br /> PE SC Received Check# Amount # <br /> 4-3 7 (5L) Z D L3�. --L) 1 a QO <br /> WELL PUKV PERNUT <br />