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WELL/PUMP PERMIT 07S730- Krus-AMI-Ip-r- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CAI I v)nc 853-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS W, ren-.2f" Ed CITYlZIP "(�3Dy r+ <br /> n a <br /> CROSS STREET �-r 5p l FLI. APN _ /'T, v <br /> ��-`I-r�J 7j PARCEL SIZE 7.Z LANG USE APPLICATION AI 0 <br /> I OWNER NAME' �F�`r}y.T y¢'-r7 C r/f S QTS PHONE <br /> OWNER ADDRESS CITY/STATEIDP <br /> CONTRACTOR V.ICi n kG Id,pr PHONE Z0'1 g4 P 17115 <br /> CONTRACTORADDRESS [.ODI &6N kprPi RCI <br /> or , / . (j!{J CITY 'p/STATEMP S4GI(1*11�/I,CA 11-M4 <br /> SUBCONTRACTOR Nb/ O4 c&-fon kw. /�� PHONE ` (% <br /> LD 3 G t_-, 3�oI <br /> OH 3L <br /> SUBCONTRACTOR ADDRESS !0Z �ydkfrr;h� V�wy CITYfSTATEIZIP ��I LyT I S Z#/MO <br /> /GL /, 7 <br /> LICENSE C-57 0 C-Bt L D-09 r Other NUMBER 6d 90I' EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ii DomestIC/Privale D Irrigation/Agricultural I I Industrial 7 Water quality Monitoring ,W Soil Sampling/Characterization <br /> n Public Water System <br /> If 011lerml from Owner a er ys em me ar am°or one u er - <br /> TYPE OF WORK 0 New Well U Replacement Well 0 Well Alleration/Modlbcation O Other <br /> U Monitoring VJeil(s) A of wells 7 Soli Bi sn9O >fGeotechnfcai a or boring, r or boring, <br /> s <br /> 7 Out-Of-Service Well 0 Out-Ol-Service Well Renewal D Cross-Connection Repair <br /> 0 New Pump D Pump Replacement U Pump Repair _ 0 Raise Well Casing <br /> WELL CONSTRUCTION - <br /> Drilling Method XMud Rotary .-,Asir Rotary rJ Auger 0Cable Tool ❑Push Point C Other '— <br /> Proposed Well Depth 6p �,`Xf( Excavation In diameter o Open Bottom D Gravel Pack/Gravel Size in diameter N <br /> C Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched C Steel C Plastic C Stainless Steel ❑Other---- <br /> Grout <br /> ther _Grout Seal Depth_f? XNeat Cement(94 lb bag/5-10 gal water) ❑Sand Cement _sack mlx17 gal water <br /> U Bentonite(20%solids) Ii Other_ (� <br /> Grout Placement Mothoi Pumped C Free Fall J Other 17 Retardant/Accelerator(name) 7Q I <br /> PEDESTAL Installed By n Driller 0 Pump Contractor U Other 1- <br /> Li Concrete Pedestal Dimensions:Width ft Length It Thick In 0 Christy Box L Stove Pipe <br /> u P C Submerslblen Turbine U Other HP Pump Set ft Standing Water Level T----,t C <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I` <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE - <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL l <br /> WORKERS COMPENSATION LAWS. , <br /> I` MI �1 <br /> M 24 HOUR ADVANCE NOTICE 1/� <br /> EREQUIRED <br /> 'FOR INSPECTIONS <br /> SIGNED_ V TITLE 1 jZGT CJ eO to Ge 4 i DATE <br /> - �`�� <br /> _ \ r <br /> T 'R/r'j y�s:i 1 K. gyp• ax,��Y'.: _ i ,-�� _ 'u�. yI•c <br /> r <br /> is <br /> 9 F. J �E r_.v*-•,«,— \��/l" - A40.N JOAQUIN OtT <br /> r DEPARTMENT USE ONLY <br /> Application Accepted By Dale I I( ( Area Employee DO <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump inspection By 7 Date WAIVER Received <br /> Soil Boring Ir!peqWon B E f �✓ __. D Constru ed Well Depth ft <br /> COMMENTS ��__ <br /> PE SC Recolvad CheckAT Amount Date Perri Invoice A Well IDA <br /> Codes Info 6 Remitted Service Request A <br /> CHC 0.1 05 - WELL IPUNP PERMIT <br /> ft+JlrJe <br />