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WELL/PUMP PERMIT <br /> S;-%JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECf1ONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> n <br /> lrl <br /> JOB ADDRESS I `!��`rz&�_1 CITY/ZIP ( l �Yr tlr y <br /> C <br /> CZ/-",t,1 106 - oya <br /> CROSS STREET /�� A�PN PARCEL SIZE ;,AND USE APPLICATION#A <br /> OWNER NAME AME <br /> an.0w/V /"/ r[o A—Sd/`� C/\JPHONE?/6-916 I.�01 <br /> OWNER ADDRESS L� <br /> SSA//�!�'Irk, ar / CITY/STATE/ZIP <br /> CONTRACTOR /V —A nV I o"� !��/�`'�"1 PHO`N�E, <br /> CONTRACTOR ADDRESS CITY/STATFJZIP /lJ��"�,V W <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATr�E/ZIP <br /> LICENSE XC-57 Cl C-61 El D-09 ❑Other N�UMBEI4-�����'3a-f EXPIRATION DATE -0 <br /> GEOGRAPHICALINPORMATION: Coordinates X Y Township Range SectioD <br /> INTENDED USE bornestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If difhren,from Ov.ner: .ler y— .me nuc,.anx or <br /> TYPE OF WO New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> O Monitoring Well(s) #of wells ❑Soil Boring(s) .°f bonne ❑Geotechnical n of boring. <br /> ❑Out-Of--Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> 'ew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method>5'Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other ,\ <br /> Proposed Well Depth7�L CD ft Excavationin diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Ing in diameter / Conductor Casing Depth P, S <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched�1�.Jt7 ❑Steel XPlastic ❑StainlessslSteel [3 Other `n <br /> Grout Seal Depth AQ0 ft 13 Neat Cement(94 1b bag/5-10 gal water) .Aff-&and Cement /y� sack mix/7 gal Wit �l <br /> ❑Bentonite(200/,solids) ❑Manufacturer Spec%solids °o Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method, Pumped 13 Free Fall ❑Other ❑Retardant/.Acceleator(name) <br /> PEDESTAL Inst&IW By ,9'briller ❑Pump Contracw ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Boz O Stove Pipe <br /> PUMP .Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level it <br /> 1 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 ACT+VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL L <br /> WORKERS COMPENSATION LAWS. <br /> ryfINIMUM 24 HOUR ADVANCE:NOTICE REQUIRED FOR INSPECTIONS _ p� ` „r <br /> SIGNED���/� F-" /,L,/� � TITLE O /r� DATE <br /> \n <br /> >' C <br /> C r %/ <br /> ` G — <br /> !! <br /> , / <br /> I III' <br /> Z D- <br /> 3 <br /> 6 - / <br /> �N <br /> 1 � <br /> I <br /> DEPARTMENT UE ONLY <br /> Application Accepted By "`" Date !!( 1 r/L� Area Employee ID# <br /> '—c <br /> Grout Inspection B ate �J�� ❑ SPECIAL Well Permit <br /> 1— <br /> Pump Inspection B .t , Dau /�/z��' ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS OL4 L Cr-C.F C G'41 6 ��"PC.Ge'" `"=� / 'l'J/4"XL G1�(.�7L&-F <-`L-!�')ICGOI�•/) ��;�, <br /> PE SC Received C Amount Permit/ <br /> Codes Info as emitted Dae Service Request# Invoice# Well ID# <br /> 131c:C 1S?� 3lS.c.v 1f 5�� yUCe3 ( lJAOD�.G <br /> 43->;v i~•c S�•tr� 5 00 � y(o3Z <br /> EHD43-02406 a:'e,$e.!'-?.�"�Lr, 'L C'',c.f�JJLC�%c i�rt1-o :�'f�..�'v�1?'%.�/-ijj G:11 j,t 3C,:e: -/-2t�"(veCL� n•.;: <br /> Il2712005 �! / <br />