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WELL/PUMP PERMIT <br /> SAN JOAQU IN COUNTY ENv)RONMENTAL HEALTH DEPARTMENT 304 E WEBER AYE 3"°FL-STOCKTON CA 95202- (209)468.3420 <br /> NON-REFUNDABLE PERNDT CA l.l. 209 953-7(+97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2 3 (p(L Cr1Y/Zip L L t/ C 7( > <br /> JOB ADDRESS r pp�� R I C <br /> • �00 l(4 O F H uJ�I I-L APN V 23 I�� L" PARCEL SIZE'` - (LAND USE APPLICATION� <br /> CROSS STREET ( A n(LA <br /> A! /v_1 <br /> OWNER NAME <br /> t" �. A 8 2A CCCh I( lw o (i r.4.a:�Q[,PHONE <br /> CITY/STATFJZI ` <br /> OWNER ADDRESS �S 1 0 I Z-68 ©�6 <br /> 1(�1 Ql �I�, �A PHONE /t q LJ/' J <br /> CONTRACTOR ADDRESS I (��OQ ,J 1--�_L\W��/�110 S J ( L (f'`7 CITY/STATE/Z P V KLA f�lA CA J / Vit- / <br /> SUBCONTRACTOR �A'•t /` t�{{N S,I--("1!� (S PHONE ✓ 6 n3? 1 v <br /> SUBCONTRACTOR ADDRESS ` "'L I P I I L r 1y CTrYY/STATE/L� •-c�/ , `(- 70 <br /> LICENSE -57 O C-61 ❑D-09 O Other NUMBER 6 6 2 70 EXPIRATION DATE J <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE O Domestic/private ❑Imigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characteri7ation ` <br /> O Public Water System mtaa me« e um N <br /> If diffcm fmm OunecW.I. .— ama <br /> W <br /> TYPE OF WORK O New Well ❑Replacement Well O Well Alterati onjodifiwtion ❑Other «� n <br /> O Monitoring Well(s) N of wells Soil Boring(s) aof borvtgs O Geotechnical g' C3 <br /> O Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> O New Purne O Pump Replacement O Pump Re air <br /> WELL CONSTRUCTION <br /> Drilling Method O Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Pant O Other <br /> Proposed Well Depth 2S fl Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Siie in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth fl (�) <br /> Well Cuing Diameter in Thickness/Gauge/ASTM Sched- E3 steel O Plastic O Stainless Steel ❑Other <br /> Grout Sol Depth L('—9 fl $JJeat Cement(9-1 lb bog 5-/0gal water)Pf-67-u40 Sand Cement sack mi:/7 gal Water <br /> `K` ❑S on File ❑S u Submitted <br /> ❑Bentonite(20°/"solids) O Manufacturer Spec%solids_"/e Nam <br /> Pe <br /> Grout Placement Method ❑Pumped ❑Free Fall O Other ❑Retardant/Accelerator(na <br /> Cc 7n <br /> PEDESTAL installed By ❑Driller O Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in O Christy Boa O Stove Pipe <br /> PUfdP ❑Submersible ❑Turbine O Other HP Pump Set R Standing Water Level fl <br /> I HEREBY CERTIFY THAT 1 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 I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1 1\1l'A1 24 HOUR ADVANCE.NOTICE REQUIRED FOR INSPF.CL'rloNs p e� <br /> SIGNED�,a,nl6i t TITLE DATE <br /> PAYMENT <br /> RECEIVED <br /> JJL 2 6 2005 <br /> AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> j DEPARTMENT U S E O N L Y <br /> Area Employee IDN <br /> S3GC <br /> Application Accepted By Date �• /2- `�S (( <br /> Grout Inspection By Date iV a ! ❑ SPECIAL Well Permit <br /> Pump Inspection ey Date [3 WAIVERReceived <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CheckN/ Amount Date Permit/ Invoice Well IDN <br /> Codes Info B as Remitted Service R uesi N <br /> +3.-? ISv `Z!� sgoo45,231 <br /> WELI.PUMP PERWT <br /> El ID<)a21)0M <br />