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WELL / PUMP PERMIT `� m 6 <br />'I—ENT—'HEALTH DEPARTMENT 304E WEBER AVE 3 -FL- STOCKTON CA 95202 - (204)468.3420 <br />NQI�-h a RMIT CALL (269) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS L� s� J+ 1yt T r `n�7 --� /. — CITYt�/ZIP_ �1� 15 _ <br />CRASS STREET ! j APN ~ .rn J i� V-7Z.kPARCEI. SIZE 3 < ' •3'3 LAND US APPLICATION #_ _ <br />r <br />OWNER NAM\'. <br />• t' <br />OWNER ADDRF.S\ _ �l- �l CJ'2rG-- CRY/STA7E/ZIPr­c_�� <br />CONTRACTOR 1�j // /((� y,ry1/ L/ PHONE�__y_ 7- �Y —' <br />CONTRACIrORADDRF.S:3 ! i��'+r�7f CTrY/STATFILII' <br />SUBCONTRACTOR _ _ PHONE <br />SUBCONI RACTOR ADDRESS CrrYISTATE/7.IP <br />LICENSE )&,-57 ❑ C-01 0D,09 ❑ Other NUMBER � EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordrnares X Y Township Rnnge Sectiop <br />NT_ENDEn USE orncstic/Nr atc C3 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring G Soil Sampling/Characterization <br />❑ Public Water System <br />If'dff—L I.. nm: WaW nmm NIAX ��iut NTame u-6hone Sum'6er' <br />rype OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other _ <br />❑ Monitoring Well(s)_. # of wells O Soil Boring(s) _ � 0 Geotechnical <br />C7 Out -0f -Service Well ❑ Out -0f -Service Well Renewal ❑ Cross -Connection Repair <br />U New <br />Drilling Method 09�4ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable fool ❑ Push Pcmt ❑ Other <br />Proposed Well lkpth-'ss:,L'SG_ R fxcavanon _�_ _ _ _in diameter ❑ (pen Bottom ravel Pack i Cravel Size ._in diameter) <br />❑ Conducto`r Casing in diameter r Conductor Casing Depth <br />Well Casing Diameter j_ in TliickncsWGaugciASTN! Schell _Z/,O- &Z- _— Cl Simi 'Klastie ❑ Stainless Steel Q Other <br />Grout Seal Depth r/�%O ft ❑ Neat Cement (44 !b bag/5-10 gal water) ❑ Sand Cement— _. — ^sack mix / 7 gal water <br />fBentonite (20% solids) ❑ blanufacturer Spee %.solids % Name _ Cl Specs on File ❑ Specs Submitted <br />Grout Placement Metkod 14limped_ ❑ Free Fail ❑ Other _ ❑ Retardant t Accelerator (name)_ <br />PEDESTAL Installed By ❑ Orilla mp=uictor ❑ Othcr <br />❑Concrete Pedeautl Dimens ons: Width S Length 4 R Tllkk in ❑Christy Box ❑Stove Pipe <br />py.+P ❑ Submersib)e ❑ Turbine Q Other HP_ _ _ Pump Set ft Standing Water Level R <br />1 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 REC.UGATIONS, 1 ALSO CERTIFY THAT MY REQUIRED LICENSE l5 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />�J /�Mj/IIfNIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />` zn.1 <br />SIGNED (/l 41QS� TITI.E_L .f , <br />ljjQN DATE e-2 �- 42Y <br />l! <br />a <br />DEPARTMENT USE ONLY <br />q fit'1414s <br />- <br />Grow <br />Accepted Ply-_: CSS' pate ( f;% Area Employee ID# � / <br />Grout InspoctiD*, By _ Dele3 yr 13 SPECIAL Well PernLt <br />Pump Inhpcction By _ _ Date ll ❑ WAIVER Received <br />Constructed W'dl Depth It <br />COMM :NTSE. 1_ T c% Cc <br />PE Sc Recdved C-0cckY/_� Anatiocif Permk/ <br />Codei lnlo B Cash Remitted Date Service Request # Invoice 8 Well IAY <br />V <br />MD 1342-006 WELL PUMP PERMIT <br />1:211'2005 <br />