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WELL/PUMP PERMIT 6130q.40-7 <br /> JA <br /> SAN OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEtfr 384 E WEBeIt AYE 3"FL-STOCKTON CA 95202 -(209)463-3420 b` <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECT IONS EXPIRES 1 YEAR FROM DATE ISSUED��o <br /> Jos A DDRFSS y\ Tom— Ada"1 1 ` -�'•+`' Pa1.Gj"/ CrrvrLtP <br /> CROSS STREET APN 2 70-2--fe PARCEL SIE ND USE APPLICATION X <br /> OWNER r L <br /> PHONE <br /> OWNER ADDRESS Crrv/STATVLIP I� •� r <br /> CONTRACTOR (�-71,r(RY/! ��h�� •j.//� }/P�HON/Enr•(J ( ) � <br /> CONTRACTOR ADDRPSS 7� lT _, )1A Y t� t P- �l CRY/STATE/ZIP d�tCA( /5, j1 J `A Q�L Q� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATEMP <br /> . OJ <br /> C.57 C-57 ❑C-61 ❑D-09 ❑Other NUMBER QEXPIRATION DATE/ Q <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INf[NDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring OkSoil Sampling/Characterialion <br /> ❑Public Water Syrtem <br /> If OiR rata from Owmr aur bystarn amr _or u <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wtll(s) M of wells ❑Soil Boring(s) a of bcrinp AGeotechnical s of borinp <br /> ❑Out-Of--Service Well ❑OutOfScmice Well Renewal ❑Cross-Connecrion Repair <br /> ❑New Pump O Pump Replacement ❑Pump Repair <br /> WELL COKMUCTION 1 <br /> Drilling Method O Mud Rotary ❑Air Rotary all-user ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth!S7--2-0 R Etcavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter <br /> ❑Conductor Cuing 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 ❑Nest Cement(94/b bag/S-!0 gal water) II❑Sand eme� sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Na f f IPOs ❑Spee on File ❑Specs Submitted <br /> Grout Pkm <br /> aeeeat Metbod ❑Pumped [3 Free Fall ❑Other ❑Retardant/Accdentor tame) <br /> PLD[STA4 Iastalled By ❑Drilla ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick to ❑Christy Bos ❑Stove Pipe <br /> In= ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Lcvei ft <br /> I HEREBY CERTIFY THAT 1 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 COMPENSATION LAWS <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FO IISP.E,,C�TrYI/n'NS <br /> SIGNED �^-� �r , 3 L­— TIT.yS' � �r�Y V"Vs DATE &1-7 <br /> 15 <br /> 17 T <br /> lS <br /> , <br /> 11N a I 1-T4 J <br /> VP L <br /> P AF <br /> - D MEN7 U21 <br /> SE ONLY -- — ---- - --- - �/�� <br /> Application Accepted Dam Area Employee IDM 11 <br /> Grout Inspection B Dam ❑ SPECIAL Well Permit <br /> Pump Inspection By JV Dam ❑ WAIVER Received <br /> Constructed Weil Depth ft <br /> COMMENTS <br /> PE I SC Received CbtsdN/ Arnount Date PesftdU Invoice M Well IDM <br /> Codes Info By Remitted Service Requea M <br /> !THD 43-47-W WELL PUMP PERMR <br />