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qW/3 p.u_pe 0.00 <br />Ct <br />kACOMketAA6 C6V1,61anS <br />CONTRACTOR ADDRESS caao (1)01,w fLoaa <br />Crry/Zip <br />CITY/STATE/ZIP .1/A q5a1a <br />PHONEZ 3L. JD <br />CITY/STATE/ZIP OA 615,91S <br />JOB /ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ;DDRESS <br />CONTRACTOR <br />q5D-t <br />ikdt AP1\9e <br /> HONE PC6? -6131 <br />PARCEL SIZE I LAND USE APPLICATION # <br />PHONE <br />SUBCONTRACTOR ADDRESS ITY/STATE/ZiP <br />LICENSE C-57 0 C-61 0 D-09 0 Other NUMBE EXPIRATION DATE "3141 <br />SUBCONTRACTOR <br />INTENDED USE 1,46 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />Submersible 0 Turbine 0 Other HP Pump Set ft 'Standing Water Level PUMP <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />in C Christy Box 0 Stove Pipe Concrete Pedestal Dimensions: Width ft Thick ft Length <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />0 Retardant / Accelerator (name) Grout Placement Method 0 Pumped 0 Free Fall 0 Other <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool <br />Proposed Well Depth ft Excavation <br />0 Push Point 0 Other <br />in diameter <br />Well Casing Diameter in Thickness/Gauge/ASTM Soiled 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 mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br /> <br />EEL <br />Uc 21 <br />NT <br /> VED <br />2019 <br />.! I 0 <br />A <br />JO • QUIN COUNTY <br />NVI - ONMENTAL <br />EA DEPARTMENT <br />dr IF .4% <br />LI(ofq P - i E T Ii S,E O L Y <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By Date <br />COMMENTS <br />A., • 1=1 <br />Date <br />Date <br />Date 5/2 wzo <br />Area 4' Employee ID) <br />SPECIALPermlt <br />WAIVER Received <br />Constructed Well Depth <br />WELL/PUM3 PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East HazeIton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />GEOGRAPHICAL INFORMATION: Coordinates X Township Range Section <br /> <br />TYPE OF WORK 0 New Well 0 Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service well <br />New Pump &Pump Replacement <br />Well Alteration/Modification 0 Other <br />if of borings <br /> <br />0 Soil Boring(s) 0 Geotechnical <br />Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />Pump Repair <br /> Raise Well Casing <br />it of borings <br />I HEREBY CERTIFY THAT I HAVE PREPARED TI-HS 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 />WORKER OMPENSATION LAWS. Bie <br />If NI UM 1141 HOUR ADVANCE NOTICE - EQU • FOR INSPECTIONS <br />SIGNED TITLE 1/ J DATE al. <br />10 <br />NMI <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />ChecloW <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />Of 697 ) 1W 1 ci -u($-77 *II/3 wPono17 <br />END 45-06 WELL /PUMP PERMIT <br />Almeria :SSBC30'9' BlIS 6/04/08