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CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR PHONE <br />Q1/4-04\& <br />CITY/STATE/ZIP <br />PHONE poc0 140-1 (1,2v <br />A-1--(teiof\,Gt fct <br />in diameter <br />Cable Tool 0 Push Point E Other <br />in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />/ Conductor Casing Depth ft <br />sack mix/7 gal water <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic El Stainless Steel 0 Other <br />Grout Seal Depth ft C Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement <br />Bentonite (20% solids) I: Other <br />Grout Placement Method 0 Pumped E Free Fall 0 Other C Retardant / Accelerator (name) <br />in C Christy Box C Stove Pipe ft Thick <br />PEDESTAL Installed By E Driller 0 Pump Contractor E Other <br />Concrete Pedestal Dimensions: Width ft Length <br />$( Submersible 0 Turbine 0 Other HP 69., Pump Set /1711 ft Standing Water Level TO / ft PUMP <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary C Air Rotary 0 Auger <br />Proposed Well Depth ft Excavation <br />El Conductor Casing in diameter <br />PAYME NT <br />RECEIVED <br />AU C U 1 nts <br />.••••• • <br />-••••".. <br />G-1 <br />Area Employee ID# <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />t uOv\ <br /> e. <br />Application Accepted B <br /> <br />Grout Inspection By <br />Pump Inspection By <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />ate <br />Date <br />Date :SS32100V 3.1.1S k")61. WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL I-1,7LTH DEPT 1868 East HazeIton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLf PERMIT410IP CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />471 cryizip-DtccOti\ 9c g12_ <br />247 PARCEL SIZE 0 .1:11 3 LAND USE APPLICATION # <br />(11(1 kA) <br />O.\ PHONE <br />Pl‘ t <br /> 7( <br />CITY/STATE/ZIP <br />JOB ADDRES1 <br />CROSS STREET 04-KW 1LAPN d - <br />OWNER NAME <br />OWNER ADDRESS <br />SUBCONTRACTOR ADDRESS <br /> <br />CITY/STATE/ZIP <br />LICENSE XC-57 C C-61 Ei 0-09 E Other <br />NUMBER 3 71 D YO EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Township Range <br /> <br />Section <br />INTENDED USE IgDomestic/Private 0 Irrigation/Agricultural LI Industrial LI Water Quality Monitoring El Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK U New Well 0 Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump XPump Replacement <br />LI Well Alteration/Modification 0 Other <br /># of borings Soil Boring(s) E Geotechnical <br />Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />Pump Repair E Raise Well Casing <br /># of borings <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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMP TION LAWS. <br />MINIMU <br />SIGNED <br />(1. <br />HOUR ADVANCE NOTICE Re:WIRED FOR INSPECTIONS <br />TITLE r rf5 DATE <br />b11/4N JOAQUIN COUNTY <br />ENVIRO4m)-ThITAL <br />HEALTH DEPARTMENT <br />ct <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />01 10° <br />Cash i 7 <br />/ 11 7(11 7(1-24v (.... ,-7 -1 0(15 400-5q5a, <br />EHD 43-06 <br /> WELL /PUMP PERMIT <br />8/04/08