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SAN JOAQUIN CouN t ENVIRONMENTAL IDEAL T li DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468--3420 <br />N00-RErUNDABLE PERMIT CAUL (209) 963-1697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DAT E ISSUED <br />X1013PODREss 1 ES�h A` a CITY/ZIP I A*4,eeA j cot <br />CROSS STREET_ N 0.KA'%*C N 61Ph 1-7-4-406-1 � PARCEL SIZE j 74AND USE APPLICATION # <br />OWNER NAME Jf/�1.��t^-� A�he�,�-�ti►� �_ PHONE (0O1—'204t <br />OWNERADDRESS �Lys,,` St�t4 Ay �'� C1r(/.TATE/ZIP MAK:6 C- A . (lei 95337 <br />CONTRACTOR AAavelIL D`i III'm im' PHONE SZZ- 192-5 <br />CONTRACTOR ADDRESS —�� <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE A C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 6ARj fn2_2_— EXPIRATION <br />GEOGRAPHICAL] FORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: WaterSystem Name Contact Name or Phone NumSer <br />o'vPE ,r --WORK New Woll ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ MonitoringWell(s) #of wells ❑ SoilBoring(s) #ofborings ❑ Geotechnical #otborings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />n New Pump n Pumo Replacement ❑ Pumo ReDair ❑ Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method �iVlud Rotar ❑Air Rotary ❑Auger ❑ Viable Tool ❑Push Point ❑ Other <br />Proposed Well Depth OC�_ft G:cavation lZ.l in diameter ❑Open Bottom Gravel PacldGravel Size_ in diameter <br />0 Conduct o Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Dov ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 'Z00 ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Ventonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller APump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Otlier HP Pump Set ft -Standing Water Level fl <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] AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE RREQUIREDFO INSPECTIONS L <br />SIGNED C TITLE U �- r " Z� V. -I DATEy� <br />m <br />0 <br />0 <br />m <br />in <br />Grout Inspection By Date PCCIAI VVeI6 R'Cr ' H <br />Pump Inspection By Date VVA vE-R Receovedl <br />Soil Boring Inspection By Date Construcied Well Depth e <br />COMMENTS 1::_5)QMA:j <br />PE <br />Codes <br />SC <br />Info <br />Received <br />BV <br />chock"ll <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request ;�� <br />Invoice # Well 04 - <br />3-I <br />''� <br />8 <br />P o6 q <br />--� <br />3 <br />�2 <br />--� <br />EHD 43-05 WELL /PUMP PERMIT <br />8104/08 <br />