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WELL/PUMP PERMIT - <br /> SAN JOAQVIN COUNTY ENVIRONMENTAL FstaaorfN DEPARTMENT 304 E WEBER AVE 3`.VeSTOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS - EXPIRES 1 YEAR <br /> GFROM DATE ISSUED <br /> JOB ADDRESS (/ V� .��Z _ CITY/21PG�"�� 1 J�) m <br /> (� H <br /> Ix'It R�r 4�rf > <br /> O <br /> CROSS STREET APN d- PARCEL SIlE LAND USE APPLICATION# p <br /> OWNERNAME -().- "F ah�.l �4��14�/jh� L eT'"1^ A. C14�4\ / <br /> y` J• PHONE Lgoq q3)- 0-3c) <br /> OWNERADDRESS laoaa 'C•.'If CO ms A),,- `'RJ. CITY/STATE/ZIP SfKN CSA <br /> " •Cf Sa/r <br /> CONTRACTOR '"IA/. -��'CA I� p4PHONE pa-6qq-03 I/ <br /> IBU <br /> CONTRACTOR ADDRESS �•D• DO)( 6�.a - CrrY/STATE/ZIP LC /l `ISd <br /> �✓/I'�7 e� 34 <br /> SUBCONTRACTOR "ZL-�L PHONE Y7/ "3��•� <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 - ❑D-09 ❑Other -' NUMBER-2K4-0- EXPIRATION DATE OS�2 0 oq <br /> GEOGRAPHICAL INFORMATION: Coordinates, X Y Township Range_-Z_E Section—a <br /> IM'ENDED USE ❑Domestic/Private )CIrrigation/Agricultural ❑Industrial ❑Water Quality Monitoring -❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> IfdiRcr I from 0— arer System amen— eme or one um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well 04 Well Altcmtion/ModificationOther `+ VA V( 3hS' <br /> ❑Monitoring Well(s) #ofwellsi• ❑Soil Boring(s) ❑Geotechnical 0 o bodnp <br /> ❑Out-Of-Service_Well ❑Out-0(--Service Well Renewal ❑Cross-Connection Repair., <br /> ❑New Pump ❑Pump Replacement -1❑Pump Repair <br /> WELL CONSTRUCTION N/A. <br /> Drilling Method ❑Mud Rotary ❑Air Rotary .t '❑Auger ❑Cable Tool ❑Push Point C1 Other ' <br /> Proposed Well Depth ft , Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size. in diameter <br /> i ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other - <br /> Grout Seal Depth ft ❑Neat Cement(94/b bag/S-/0 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(200/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Ii Grout Placement Method ❑Pumped- ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> i <br /> PEDESTAL 1J'./� Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP_. VA ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft <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 REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE-LICENSE. BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKTION LAWS. <br /> MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED= TITLE DATE IyOaz <br /> 104W71 m1up <br /> - <br /> t <br /> i <br /> 1 <br /> 1 <br /> E <br /> 11 Z <br /> O <br /> SAN <br /> TY <br /> E y( O N <br /> —11 DEpAF TM <br /> 1� <br /> D Ar TMENT USE P IN LY <br /> Application Accept T Date Area Employee <br /> Grout.lnspection By z2 4. Date n ❑ SPECIAL Well Permit <br /> .e Date - ❑• WAIVER Received <br /> nsp <br /> on <br /> Constructed Well Depth <br /> ' COMMENTS <br /> PE SC Received Chec Amount Dare Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted rvice Request# <br /> I.1]/I005 MP <br /> WELL PUPERMIT <br /> -02-006 <br /> Ill <br />