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SAN JOAQUIN COUNT)! ENVIRONMENTAL HEALTH DEPARTMENT .104 E WEBER AVE 3."' FL - STOCKTON CA 95202 - (209) 468-1420 <br />NON-E1 c—FuNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED • <br />at 0 <br />952-ad <br />PHONE <br />WELL / PUMP PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />LE . „ <br />Tilt_cf4Ae..<?‘&ti <br />IP <br /> 14:41 CITY/Lip <br />_ - <br />APN r) 0 7 ° ---.14P ARC EL SIZE 615.- 2-1- LAND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP gdarti <br />Crty/STATtiZar- <br />PHONE <br />CONTRACTOR ADDRESS <br />SUBC.oNTRACTOR <br />SUBCONTRACTOR ADDRESS Cm/STATE/Zip <br />LICENSE.12((-57D C-6i U 1)-09 0 Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates Township Range . Section <br />1 <br />9 gy <br />INTENDED Us K Domestic/Private rrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />if itlierani from Owner: Water System Nerve Coniact -Niane or Phone Number <br />New Well 1141acement Well <br />0 Monitoring Well(s) ft of wells <br />0 Out-Of-Service Well <br />o New Pump 0 Pump Replacement <br />TYPE OF WORK 0 Well Alteration/Modification 0 Other <br />Soil Boring(s) # of boriogs <br />0 Geotechnical <br /> N of boa/rigs <br />O Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />ICH'rtnip Repair <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 17:1 Air Rotary 0 Auger 0 Ifrfel.--).1-e Tool -0 Push Point 0 Other <br />Proposed Well Depth 5.4911_, ft Excavation fi in diameter Iii.61en Bottom 0 Gravel. Pack / Gravel Size - . M diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter /2._ in ThicknessiGauge/ASTM Sched , /S 87 teel ' El Plastic 0 Stainless Steel 00 et' <br />Grout Seal Depth 51;) ft 0 Neat Cement (94 lb bag / 5-10 gal water),.and Cement sack mix I 7 gal water <br />0 Bentonite (20% solids) 0 ManufacturerSpe...5.5' solids % Name 0 ees on File CI Specs Submitted <br />Grout Placement Method C Pumped 0 Fret Fall Other/ a 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller A0timp Contractor O Other <br />ft Thick in 0 Christy Box 0 Stove Pipe 0 Concrete Pedestal Dimensions: Width - - ft Length <br />Lus_te 0 Submersible 0furbine U Other IIP • 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI <br />SIGNED <br />24 OUR ADVANCE NOTICE U112_§_lit FOR INSPECTIONS <br /> TITLE DATE -4 "." (f) <br />fct <br />1134A-4- <br />PO WO) <br />ceCE. <br />\ <br />7 <br />:‘1Lit5.4iit44e,L1.4 <br /> <br />,l0f\Q <br />01 <br />0401;.-/N <br />viEjk(o Ft. <br />Application Accepted <br />Grout Inspectio4B <br />Pump Inspection B <br />Constructed Well Depth <br />COMMENTS <br />- <br />DEPARTMENT USE ONLY <br />Date if 'F 0 Z Areas Employee IDO <br />Date •••••',X 0e, 0 SPECIAL Well Permit <br />Date .9-,.:(i-2-0/0" , 0 WAIVER Received <br />ft ..nr- <br />.5 3 c'Yqi' <br />PE <br />Codes <br />SC Received <br />Info By <br />&Width"' <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request a Invoice a Well IDa <br />3 2_c. ,to 'fir?' ....51.005:3 ER lI tiftD21 (3 <br />L f3E-t) <br />7 <br />os`o vif E)02--i6H <br />END 43-02.006 <br />1/27/2005 <br /> <br />WELL PUMP PERMIT <br />