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a <br /> WELL / PUMP PERMIT , _rED- <br /> SAN <br /> " `! l-SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT 304 E WEHER AVE 3P°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I-7w,!A.1d4+✓� Ml,"A ('�' 3'a0 CITYIZIP <br /> a <br /> TS �.., S Gbh U=- ?� <br /> CROSS STREET 14"+oT i �1-] oti R v4 1'2- 1APN 6L(,�q.1-- V30-- 39 PARCEL SIZE + LAND USE APPLICATION.,t# <br /> OWNER NAME 4L���0. 1�4. 5 PHONE(Zjj('). f s-A -S[SLo G <br /> OWNERADDRESS @ � CITY/STATE/ZIP' T0. ""�'"�' y -`5� <br /> Tais�+-t -n5r+�.��•-►\n `a 1�e)_3 <br />� <br /> CONTRACTOR PHON£ <br /> CONTRACTOR ADDRESS tSE `-`,+'�� /lcY�W uA_ L4-5�� �y�yr�rO Ce' 9S1+`� <br /> CITYISTATE/ZIP <br /> �a\ �1tiS =K[�h'1ux Lt q25 4b� o <br /> CQ t�� �A +� c 1 <br /> SUBCONTRACTOR -'(' <br /> PHONE <br /> SUBCONTRACTOR ADDRESS Z� k C' CITY/STATEIZIP <br /> I <br /> LICENSE ;KC-5713C-61 13D-09 ❑Other i NUMBER E EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X �`53� ' Y 25,04;10 Z'to 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: Water System Name Contact Name or 114one Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well Q Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells #ofwells ❑Sbil Borin s sof borings UGeatechnicalagvfborings "n <br /> ❑Out-Of-Service Well El Out-Of-Service Well Renewal 0 Cross-Connection Repair ' a®U0 r `� <br /> ❑New Purne ❑Purnp Replacement ❑Pump Repair <br /> WELL CONSTRUCTION _ <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft' Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ! <br /> ❑Conductor Casing in diameter ! Conductor Casing Depth ft I ' <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched. ❑Steel ' ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth010''�64 R (Neat Cement(94 lb bag/5710 gal water) ❑Sand Cement sack mix!7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File D Specs Submitted I <br /> Grout Placement Method Pumped ❑Free Fall 0 Other ` ❑Retardant!Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor..N. ❑--Other <br /> 13 Concrete Pedestal :Dimensions:Width ft Length ft Thick in ❑Christy Bojc ❑Stove Pipe . <br /> PUMP ❑Submersible.❑Turbine ❑Other HP Pump Set R Standing Water Level ft, <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN j <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT'MY-REQUIRED LICENSE IS <br /> CURRENTAND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. . : '► <br /> '/ ` I'VA.NCE NOTICI l2FQUIRF..D ICOR INSPECTIONS i <br /> SIGNEDDAT£/ O 7- 1' <br /> f- z-,4 <br /> TITLE <br /> v <br /> l <br /> - DEPARI MENT' U/,3/07 : <br /> E" ONLY - — <br /> Applicatio�� cepted lay Date CEmployee ID# � � <br /> �.fs7euJ t Inspection By- Date C �✓ ��t �f�6PECIAL Well Permit / <br /> Pump Inspection By Date— APR13 WAIVER ReCeived <br /> Constructed Well Depth It U .3 2007 <br /> $AIV JQ <br /> ! <br /> COMMENTS .� �?�,e .. ` ►"7 , <br /> IVIM <br /> PE SC Received Check#! Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request Invoice# Well ID# <br /> ti <br /> L1377 150 s10 V3 V-0.t� 9 5 -5019 q <br /> EHD 43-02-006f�' �,�- �� -Z'�V 1 ^`- L4v'1•r/ WELL PUMP PERMrr <br /> 1/27/2005 <br />