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vWELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER STOCKTON CA 9$202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED -J 1�/n' j /(� �j N JOB ADDRESS 7 I Gl✓L-L 1 C CITY/ZIPf-L�'s'V✓1 `S � )� m a 1L_ CROSS STREET 1,L1' LI APN /�0��--G'/Qt/-rt/✓.-`-.I . PARCEL SIZE LAND USE A/PPLICATION#��yrj'T OWNER NAME �kli✓�-�i tsj,1>�A. 1 ](•-(,`) .q{ � at't"( l vitt' lir-Gine- PHONE/ 1�rt(� Ib'ta �ti er I m DWNFRADDRESti Cll"Y/ST'A'1'iJZIP a l-O eiIL CONTRACTOR S,J�. PHONE CONTRACTOR ADDRESS CITYISTATE/ZIP SUBCONTRACTOR L�1 �l11't t� �r5 PHONE �� S�/Cl 2- SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-$7 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Cl Soil Sampling/Characterivation ❑Public Water System IfdiHerentfrom Owncr: attr Syst..N.. Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alleration/Modification ❑Other ❑Monitoring WCII(s) #of wells ❑Soil Boring(s) x of sonays ❑Geotechnical a°f a0p°gs ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pump ❑Pump Replacement ❑Pump Repair WELL CONSTRG ION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other V� Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Siu in diameter •� ❑Conductor Casing in diameter / Conductor Casing Depth it Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement(94 11,bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Ii7 Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width it Length H Thick in ❑Christy Box ❑Stove Pipe rN PUMP j Submersible 13 Turbine ❑Other HP Pump Set H Standing Water Level ft l'• I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS rj CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE RE"RED TR INSPECTIONS j�.�� [ r.T .�C.> DAT SIGNED - r b� A O•p 6i ''[qy �• ` s � g7g JD Pill x111 € PAYMEI' .Ile, er RECEIVI AUG 10 SAN JOAQUIN d $ a b Yi ENVIRONME IV E 'x-e3V= '" E� HEALTH DEPAHI MGN, .N'KK n.R.Ct.00N :n ----------- it j farm°w�irUBr� S @ J }�4., --------------- -- — -- xot s.noaa of aolxd R�X3 g . -• I+s: :•: r,. :? > Application Accepted By 1 Date 0/1 L's Area W N Employee ID#-S lLl "//7C,7 /c. `t Grout Inspection By gZ Date Q ❑ SPECIAL Well Permit Pump Inspectio Date !��✓f/lT ❑ WAIVER Received Constructed Well Depth fl COMMENTS -TZ: S'+177GF v/ C.y` /)+'770'-) a L CF 1?A- L`L{ -S-I`] W:L� rhL a4i7L� CL7av Z71 u[ 7 r7 b�LrT . PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Dale Service Re uesI# Invoice# Well ID# i - 1]111341-02-0 WELL PUMP PERMIT 1/2712005 trr