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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3tO FL-STOCKTON CA 95202 - (209)468-3420 <br /> • NON-REFUNDABLE PERMIT 2 CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ra <br /> JOB ADDRESSZ2SS-0E.LCaI$ (� 1� _ Crrv2>P�C�CME Iv I S n <br /> �t <br /> ( O <br /> • N 1.) ppN <br /> 02-1 z O Z 3 PARCEL SIZ 90 a�LAND USE APPLICATION N <br /> CROSS STREET lu" <br /> OWNER NAME M I N'�(� M C P,-, S rl 1 Mill P--t C N S PHONE w <br /> 1 � I <br /> OWNER ADDRESS CITY/STATE/LIP <br /> LCpS3 Li�%^(� vJ(wp WLRSL �Nf A PHONE Z-68 01061{I <br /> CONTRACTOR ADDRESS `J �LlW � J ( L CrrY/STATFILEPVI <br /> , n Q r.i •� <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS J ` IAC <br /> I 7L 9 6 3 6 y 3 <br /> CITY/STATE/L� C� C m,-.4 In S j <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER 6 2 1a 0 EXPIRATION DATE <br /> I Jos <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characterization <br /> ❑Public Water Systeme <br /> If diff—I from Owner: .Ter �slem .me mwmea um <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other N <br /> ,3 Odb—p ❑Geotechnical Nof�E' N <br /> [3 Monitoring Well(s) N of wells Soil Borings) l- <br /> ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair v I <br /> O New Pump ❑Pump Replacement ❑Pump Repair v f <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rouig ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ';� fl Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter m <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter 11g in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ?d Neai Cement(94/b bag 5-/0 ga/water) ❑Sand C e 11 sack mix 17 gal Water (� <br /> cs Specs Submitted <br /> ❑Bentonite(20°/.solids) El Manufacturer Spec%solids_'. Name ��C"�� ❑S{x File ❑ P J C S <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller O Pump Contractor ❑ OtherItl <br /> ❑Concrete Pedestal Dimensions:Width ft Length It Thick in ❑Christy Bo: ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set fl Standina Water Level R <br /> 1 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 /> vINIU'M 24 HOUR ADVANCE NOTICE, REQU ED FOR INSPECTIONS L <br /> nit p rte,,�f ls'�' �-U.�E <br /> SIGNED <br /> Awl/ EJN'`^"�Oe"s" �- <br /> TITLE <br /> I I I I M1 <br /> PAYMENT <br /> RECEIVED <br /> 2 6 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> DEPARTMENT U EON LY /^ <br /> Application Accepted By ,,11 C� `�- Dale 7 �r �S Area Employee IDN �3&" r4 <br /> Grout Inspection By /`d'L Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received (Ch-W Amount Date Permit/ Invoice Well IDN <br /> Codes Info B ash Remitted Service R west p <br /> tt3.tv f sEi 0 2�c. -� 7 yL 0 OD <br /> WFI.I.PUNW PERIAT <br /> FJ ID 43414X)6 <br />