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TMENT U ONLY <br />ate <br />WELL/PUMP PERMIT * <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS IEXP1RES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS , 1 v b .‘ et/A,/, .4 .4 cirdzip LAtiOte 7.-4 3 7 <br />CROSS STREET xid_KI,...ky/Vo#eic e-:,,I.,L, 2_4 I - Lk c).6 - 3 1 PARCEL SIZEt kAND USE APPLIC,6.TION <br />OWNER NAME -ttk_ Ve.,....v,-d L..,..,.7.._ f"---<_6 ( 6epo Le.citi ap "C....) PHONE Z69 -3Ct, 4513 <br />- 4 L;(4-e- i 04 FVSTATE/Zip 1_49-7 6...4z4 I C A ) 7 5c 2-- OWNER ADDRESS I 13:7 9'9 1-4.1" 4v&l <br />CONTRACTOR —6246,72.43--r-Lr-cf s 5e. I'l PHONE <br />CONTRACTOR ADDRESS .- CITWSTATE/ZIP ..--- <br />SUBCONTRACTOR PHONE <br />SUBCONTRACT ADDRESS WY/STATE/ZIP <br />LICENSE -57 0 0-61 0 0-09 0 Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /># of borings # of borings 0 Monitoring Well(s) # of wells 0 Soil Boring(s) 0 Geotechnical <br />Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 ew Pump 1 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION • <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schecl 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mixl7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP 0 Submersible 0 Turbine 0 Other HP Pump Set ft 'Standing Water Level ft <br />I HEREBY <br />JOAQUIN <br />CURRENT <br />WORKERS <br />SIGNE <br />CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />AND ACTIVE • WITH THE CA IFORNIA CONT CTORS STATE LICENSE BOARD AND THAT .1 AM IN COMPLIANCE WITH ALL <br />COMPENS - N LAWS. /Ifs <br />I<I;ANCE NOT REQUIRED FSPECTIOAIS <br />A AWitilliaadOW D.* 3/zLize 1 cc <br />trOA <br />t:47--- hyr-if 410141 2 p 4 <br />%dal V 204 AIL,.42 #;,94,11v <br />*-147.84°4.46tiEvagzivr <br />- <br />Pdp, <br />"ftrr :sSACIayi EilS Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS el \KC, 04( SCG-ClAct-''‘,," \1•),&)-- <br />trey, <br />Area Employee ID#A14014 <br />Date SPECIAL eil Permit <br />Date WAIVER Received <br />Date Constructed Well Depth ft <br />CC/0)-Y*- tAh e‘c-, of- os tot 4)) <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />1,1ecle) <br />as <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well E:)( <br />01*(1 6 /0 7 t qt- (7/7/ 12(Plo WP00361(41 <br />END 43-06 WELL /PUMP PERMIT <br />8/04/08