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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'•FL-STOCKTON CA 95202 - (209)466-3420 • NON-REFUNDABLEPERM]T n CALL 209 953-7697 FOR INSPECTIONS EXPIRES IAYEAR FROM DATE ISSUED y JOB ADDRESS r c(r /�•`- 8 6^��1Y �` CrrY/Z� �� B' M CIc ST LL CROSS STREET J1G RI! z� V/l APN�J (60 I L PARCEL SttF;-6k+ rt SLAND USE APPLICATION 1l a O L I (L . K OWNER NAME GJn�IL /� r7 PHONE OWNER ADDRESS CrrY/STATE/LP (G a S L pj'iJ G R� tri L S (� N PHONE (_ )/Z/�L ) 16- 4 j��Jy/'61 a CONTRACTOR A DDRESS I (_]00-1 _'-q..L�W: �/S �S J(( ( (' Cr1Y/STATE(L[P;O I K L A(`I(� 1.A ) / 6- I SUBCONTRACTOR �5'LCL l/af'hili fI I"i.1 R 1 � t yyP��HUNE 9 6 n3A� I_(? 3 J I�t S l C (I (�I 1 y Crry/STATE/LP 1�►LX C r C rY/O C SUBCONTRACTOR ADDRESS ` �7 LICENSE -57 O C-61 ❑D-09 ❑Other NUMBER V `70 EXPIRATION DATE J GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section INTENDED USE ClDomestic(Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characterization ❑Public Water System .[..I .me« ane um If differ-I from Owner: W.I. )-A— •me TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Mification ❑Other It of b«in ❑Monitoring Well(s) k of wells Soil Boring(s) a of bonnps ❑Geotechnical Br ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair 1 ❑New Pum2 ❑Pump Replacement ❑Pump Repair WELL CONSTRUCTION r� Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 9-5 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter p, ❑Conductor Casing in diameter / Conductor Casing Depth R r_ Well Casing Diameter T-5 in Thickness/Gauge/ASTM Sched 13 Steel 1❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth fl pUvew Cement(94 Ib bag S-l0 gal water)(f-6r)O�C� t sack mix/7 gal water ❑Bentonite(204/6 solids) ❑Manufacturer Spec%solids_% Name O CF/ilte� 0Specs Submitted N Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Dri Ilef ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:WidtA fl Length fi Thick in ❑Christy Boa ❑Stove Pipe ; PUMP ❑Submersible []Turbine ❑Other HP Pump Set It Standing Water Level ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 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. N1IIN MUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS R pYL�1C-.—T M.R f✓pG�-R-' DATE �- E��Og Iv SIGNED TIT] V V2 n V..ES�t' 7` ='AYM E NT RECEIVED sA 2 6 2005 AN JOAQUIN COUNTY ENVIRONMENTAL EALTH DEPARTMENT pEPARTMENTSE ONLY Application Accepted By ''""/1` 4 - Date Z "S CS Area Employee IDN �`3 %Q01 Grout Inspection By Date �t ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Constructed Well Depth It COMMENTS PE SC Received Chec Amount Permit/ Invoice Well IDN Date Codes Info B Cash Service Request N Remitted q3.7 1:5,L) .23U•oUZR—6 z2 WELI.PUMP PERMIT eJ ID 4NIIaMAS In7n(m),