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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENV IRON MENTAL HEA LTH DEPARTM ENT 304 E WEBER AVE 3"O FL-STOCKTON CA 95202 - (209)468-3420 • NON-REFUNDABLE PERNHT CALL. 209 953-7697 FOR INSPFCIIONS EXPIRES I YEAR FROM DATE ISSUED Iw Joe ADDRESS ( ✓ I h � ' �I> CIn2>P � > / (} I • CROSS STREET -t`I'I IQnL/" i L��-f1� r�I� (�APN/�(2- Z I 1/��J PARCEL SIZE ""' } LAND USE APPLICATION'it OWNERNAME V L 1`� 1 "�� LLE F�A rJ 1-3.( rcC I u PHONE - OWNER OWNER ADDRESS i1 /l LO t4 5,)1,1 Ilaamqgariff INC PHONE 1 0�/Z-68 o i`1 6 I] CONTRACTOR A DDRESS (IJ JQ {LG V.1.,ay CRY/STATE/Z.� K L f`Lgil C A ) -/6. / SUBCONTRACTOR I n 12'[�:i'` 7�� (i(�i d N (� ! PHONE ✓ n�,t� I " J`� SUBCONTRACTOR ADDRESS J l I( to C I C'1 r,1 I `L V /�C}rrY/STATEJLIP L� LICENSE -57 ❑C-61 ❑D-09 ❑Other. NUMBER I V 6 2 1'3 EXPIRATION DATE I J GEOGRAPHICAL INFORMATION: Coordinales X Y Township__ Range Section_ INTENDED USE 13Domestic/Private ❑Irrigation/Agricultural ElIndustrial ❑Water Quality Monitoring oil Sampling/Characterization ❑Public Water System .-I sme a ooc um If diff—I from Owner: aier sA�+n am< TYPE OF WORK New Well ❑Replacement Well ❑Well Alterationcation xof 0 Other -'of Inrinp ❑Monitoring Well(s)_g of Walls �i Soil Boring(s) /M ifi ❑Geotechnical ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair I`4) ❑New Pump ❑Pump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth u fl Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diamew ❑Conductor Casing in diameter / Conductor Casing Depth fl ,1' Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ,❑Plastic ❑Stainless Steel ❑Other I Grout Seel Depth fl Neat Cement f9J/b bag d-/0ga/water)t E-G ❑Sand Cemept sack mix/7 gal Water ewf c'�.c.:k- t ❑S cs on File ❑Spe Submitted ❑Bentonite(20%solids) Manufacturer Spec%solids_•/. Nance �. N L.S Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name G� Gu TFT PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other El Concrete Pedestal Dimensions'.Width k Length fi Thick m ❑Christy Bos ❑Stove Pipt pU� ❑Submersible ❑Turbine ❑Other BY Pump Set ft Standing Water Level fl 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAW'S,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. I J 11N 91`N1 24 HOUR ADVANCE:NOTICE REQUIRED FOR INSPECTIONS I /�,�y��Q �` DATE -7 -1 g -0- ! SIGNED Ptd""""�` TITLE ------------ =AYMENT RECEIVED JAL 2 6 2005 AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DEPARTMENT USE ONLY s3�L !/IQ Application Accepted By �- �- Date 2 Z 6, O. Area Employee ID# 7 - -,J Date `� L"E' G s ❑ SPECIAL Well Permit Grow Inspection By � l'"t^"'"`'` Pump Inspection By Date ❑ WAIVER Received Constructed Well Depth rt COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice N Well IDH w Codes Info B u Remitted Service R est# If 3 7z 15C, 0 0-L^ 1,t d 00 3.22�i Wh.1.l.PUMP PERWT fl l O�).n3axM