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w WELL /-PUMP PERMIT I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1 JOB ADDRESS t.1fpt�& NW tblbk4rca Or Ai)lyzT +zz `; F� i� '��-. CITYIZIP 013 jVD V5 �d v CROSS STREET APN i,S d C7 PARCEL SIZE 5�-u-t" AND USE APPLICATION# p to OWNER NAME �[�. �OIJ SI�IPa1...ir1�L PHONE ,1 'n OWNER ADDRESS Z Off, � �� - � � 3 �' Sv�lT1r CITY/STATE/ZIP_-S" LY C -X{,KOnf I LSA 95--b'1 CONTRACTOR �s'c 1 L. � 4a=R-SO N Stu A-yi_-S PHONE- 31,' -j 444 n, CONTRACTOR ADDRESS AO-L S1.�n►tiSCiZ�P�L vJi� _ CITY/STATE/ZIP 1►13t7i C_ipt SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS ICITY/STATE/ZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 1O WA 0 0 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name , . 11111!1111IMra u I. e TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells SoilBoring(s) io_-1 sPLwrmit may hveowpiceftWatbonngs ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal NOkVnM'ThfeU OC inspected❑New Pump ❑Pump Replacement ❑Pump Repair t� I WELL CONSTRUCTION I..IiVjronm ,a ea L ivi'sion Drilling Method 0 Mud Rotary ❑Air Rotary *uger ❑Cable Tool ❑Push Point ❑Other IProposed Well Depth 113 r VS R Excavation SQ in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth ft E^ Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other V i Grout Seal Depth it ❑Neat Cement(94 lh bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name Sow CAt"CTSN( ❑Specs on File ©Specs Submitted Grout Placement Method ❑Pumped Lkftee Fall ❑Other ❑Retardant l Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor N Other ❑Concrete Pedestal Dimensions:Width Length ft Thick in ❑Christy Box ❑Stove Pipe r PUMP ❑Submersible ❑Turbine ❑Other HP p et ft Standing Water Level fl 1 I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE f FF �fAlE�1 DATE !� 0 - - - SOUTHPARK., T E VIJA -UNIT NO. 1NO 1 2.9-69 -- 2 — 5 I MADRID # - N Ni _ II. F PARK LOT;:(E) II v`Ii Il j - II Il - . .......... .._ 1 I �•• I 1 PARK.,LOT hA1rj ,u AIt 'J ' 7— _T' --I T T . I T� m j ji I —. jI j�. .I ffi,m� RIS - - 21 - PARK LOT`(E) II 81 = I LT U I -------- II JULIET _ -TERRACE j 38-45 I 111{ , DEPARTMENT USE ONLY - _ - „ Application Accepted By— �� -_..--- _ +_Date=_-1 3 j 40. . .Area Empioyee-ID# _q__VS Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date '13' WAIVER Received Constructed Well pth ft COMMENTS r v PE SC Received Check# Amount Permit/ Codes Info B ash emitted Date -Service Re uest'# Invoice# We11ID# X3.7 I'T-0 Lk 210,&11 .. 41116"391- FHD 43-02.006 f- WELL PUMP PERMIT - 1/27/2005