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WELL `UMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 31°FL-STOCKTON CA 9520�/�19)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 -7697 FOR INSPECTIONS EXPIRES I YEAR FRON.'�ITE ISSUED <br /> H <br /> 60 <br /> JOB ADDRESS L iJ Lt r DC L 13,)-)*1�y�C:C- led. CITY/ZIPS 4 / _ - 9 <br /> CROSS STREET_ I i Jam/v APN V I7 -/6 qO-LlZ-PARCEL SIZE 45W-404tAND USE APPLIC/A�TION# _ - <br /> OWNER NAME J�/rC N/JfC Ls"a �L1C�C L.�f 3 61-12 <br /> PHONE �'rY v /_�� y <br /> OWNER ADDRESS �I �LK- CITY/STATE/ZIP &kJ eD Si OC 7�j-r C/6 2-1 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITU/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 13Domestic/Private rrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If diffemm from ec Water System Nsme Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of bonngs ❑Geotechnical #of borings <br /> ,XOut-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump 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 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 1b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water , <br /> ❑Bentonite(20e/solids) ❑Manufacturer Spec°/solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width It Length It Thick in ❑Christy Box ❑Stove Pipe 6 <br /> l� <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN�AT19 S. <br /> �ML]VI1 UM 24 HO�VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED / , TITLE e!!�'.uN 4-14— DATE -03 e 011 <br /> O N <br /> S N p M N T <br /> LT � <br /> DEPARTMENT USE ONLY <br /> 3 /a ob s.3io(o <br /> Application Accepted By Date Area Employee ID# X79 <br /> Grout Insp Date ,./ ❑ SPECIAL Well Permit <br /> Pump I pection By Dat��c7CJ�d,.0 ❑ WAIVER Received <br /> Constructed pth ft r <br /> COMMENTS r,G�� yrs✓�-6 y� �Jr✓ -' - -r (G -?R-0-3 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# ell! <br /> Codes Info By ash Remitted Service Request# <br /> tau y <br /> 43 <br /> END 41-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />