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j'` q4 <br /> WFzL!iII'--UPvhF'PEHR M V <br /> SAN JOAQUIN GOUNTt ENVIRONMENTAL HE.ALTi-i DEPT 7868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> N D\1-REFUNUAGLE PERMII- CALF(209).9.53-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DANE ISSUED <br /> L,1 , , Ln <br /> JOB i-DDRESs � �'1 LI L4 !�,• ��r-E.�'t- �1__G� Cmr/ZIP �t—��Ca� 1����_ <br /> 0 <br /> CROSS STREET ��Cv�C� C_!,,,kD d�si 2-c:> 01 PARCEL SIZE AND USE I-'��PPLICATION m <br /> cn <br /> OWNER NAME JA Q 1� (! tQ Vl C.5 PHONE }1 ci Z- So 3 <br /> OWNER:=:DDRESS ��7� ',eob'Lhc Gall, V`' Cl—r,'/STATE/Zips TOC-L-4U/1 <br /> CONTRACTOR Mais1t.lIIC �'t t�lthe ��. PHONNE C�2-2 - 1 .� <br /> CONTRACTORADDRESS L `.C1 Iy��J 1�"1 CITY/STATE/ZIPMadeG ie� j vo__I !9S• 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR:ADDRESS CITY/STATE/ZIP ^� <br /> LICENSE -')<C-57 ❑ C-6.1 ❑ D-09 ❑ Other' NUMBER C -' EXPIRATION DATE ��' I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range S IOn <br /> INTENDED USE ;Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characte'i on <br /> ❑ Public Water System <br /> If different from Owner: Water Sys em Name ontac ame or one NUm r <br /> TYPE OF°.11JORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) of borings ❑ Geotechnica +A of borings <br /> ❑ Out-OF-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Rep <br /> ❑ New PUMP ❑ Purnp Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling iliethodV Mud Rotan,, ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well DepthS!jC> ft Excavation 1_ in diameter ❑ Open Bottom �G v I Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth <br /> UVeII Casing Diameter in Thickness/Gauge/ASTM Sched l� ❑ Steel Plas' Din.less Steel ❑ Other <br /> GrOLItSeal Depth 1O0 ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ S d el sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Methoasiepumped ❑ Free Fall ❑ Other tar nt/ cc er o (name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Oth <br /> ❑ Concrete Pedestal Dimensions:Width Len h Thicl in ❑ Christy Box ❑ Stove Pipe <br /> _PUMP ❑ Submersible❑ Turbine ❑ Ofher NP ump e ft `§tanding Water Level f[ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICA A D I FI THE WO Nil L BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES R U T IONS. ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRAC— R T TE ICENS CARD AND THAT.I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HO AD T E /RAJE I D FOR INSPECTIONS <br /> -SIGNED TLE iDATE 3- /— /7 <br /> P <br /> , ` eo <br /> E Q I <br /> P C y M T UN7Y <br /> po.N 7644 MT <br /> -7 v — <br /> DEPARTME , OAa.. <br /> Application Accepted By .i Date Area q Employee ID# 7 S�P/�O LfGC�S <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring inspection B\ _Date Qonstru ted Well Depth ff' <br /> COMMEhITS <br /> PE SC Received - Amount pate Permit/ Invoice# Well IDA,Info B ,ash Remitted Service Request <br /> t� 33d3��_dv 3 to SKoO�(o �8 <br /> EFID 43-06 WELL/PUMP PEI <br /> u/04/08 <br />