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WELL/PUMP PERMIT <br /> 9101 17 46� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202- (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 PoR INSPEC71ONS EXPIRES I YEAR FROM DATE ISSUED <br /> �y rn <br />� J aADpxESS ��'-+p°C G l��vLler Lo�Y� CtTY21P "1 "' <br /> t � <br /> v� <br />' ROSS STREE APN PARCEL S1ZEn•b LAND USE APPLICATIONa <br /> I # +7fi1� <br /> 4 OWNER NAME �� �+ ►C.F A�-Lr1/ T.q.t�1�r. ACV- PHONE �AJ'Jti S"4 7-A—14% N <br /> OWNER AaDxL55 36 30 ¢OSS 4+y�'� f'lV�1XVs� C[TY($TATEl7,IP + p merry, A bevy p LIC) <br /> I CONTRACTOR W s tnl '�s; <br /> T <br /> CONTRACTOR ADDRESS Inrt7 Y S�T 5T <br /> i A1 ( ti <br /> SUBCONTRACTOR i Ai.� P O <br /> I <br /> SUBCONTRACTOR ADDRESS C ,! TATFaIP r <br /> LICENSE INC-57 ❑C-61 ❑D-09 ❑Other �1 p� N[)MaE <br /> GL+OGRAPHICALIN'PORMATION; COOrdinatm X 319'•�� '1 fl 1 Y <br /> ENTENDEO USE Cl DOmesTlclPrivate Q Irrigation/Agricultural D Industrial D Water Quality Monitoring pSuil SamplinglCharacterization <br /> ❑Public Water System ! <br /> if dificrcnt from Owner. Zliater hystem NAM Comet Narre or ne u e <br /> TYPE OF WORK D New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other W <br /> 13 Monitoring Wells Hof wells ❑Soil Boring(s) #of boringseotechnical <br /> —KoCbatin <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Cann on Repair <br /> 11 New Pump ❑Pump Replacement ❑Pump A air <br /> W ELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary I7 Air Rotary Auger D Cable Tool Cl Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom D Gravel Pack!Gravel Sim in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter in ThicknesslGaugeIASTM Sched D Steel O Plastic ❑S_ta' less Steel 11 Other <br /> Grout Seal Depth ft 'Neat Cement(94Th hag/S-IO gal water) Sand Cement & Li• sack mix 17 gal water t <br /> Q Bentonite(20%solids) 17 Manufacturer Spec%solids % Name IL D Specs on File D Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall D Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 17 Driller 11 Pump Contractor CI Other <br /> ❑Concrete Pedestal Dimensions:Width fl Length ft Thick in Cl Christy Baa El Stove Pipe <br /> PUMP ❑Submersible O Turbine 17 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> N1INIiVIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED (7"-x/`- TITLE DATE E /21 b24 <br /> DE ARTMENT77 U pE 0k�y'LY <br /> Application Accepted By <br /> Datej:[ 6 Area Employee IDN <br /> Grout Inspection By Date 13 SPECIAL We11 Permit / <br /> Pump Inspection By Date 0 WAIVER ReeeivCd <br /> Constructed We1E ep ft <br /> COMMENTS: yfr r`- 4� <br /> tj <br /> PE SC Received Chet Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 4 1 01.S2oo iF 5 <br /> EBD 43-,22-006 W ELL PUMP PERMT <br /> 1127,2005 <br />