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VELL / PUMP PERMIT SCAa `7 JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPAKfMENT 304 E WEBER A. 0 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP ��-vZ, E l e2`.� eet v c CROSS STREET ``� '( (yl APN 2-22- - 310-C>k'PARCEL SIZE t)'3 L/ LAND USE APPLICATION# OWNER NAME /f V e L cac It OWNER ADDRESS/c�"`� / L d U �r V� % C' G CITY/STATE/ZIP C��' t��K C7LJ r CONTRACTOR f ✓ 1C��// I- ��/Ir K7 �PHHOO�NF�72 CONTRACTOR ADDRESS I l llJ��'S CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /r LICENSE 7 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATt24r GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE #51:QQmestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different fromOwner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well X0lacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTJOO Drilling Method PeUud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth /&0 ft Excavation A? in diameter ❑Open Bottom 1KCIravel Pack/Gravel Size in diameter ❑Conductorr/ ft Casing in diameter / Conductor Casing Depth Well Casing Diameter G/' in Thickness/Gauge/ASTM Sched_Z:.6fr)75 ❑Steel �'hlastic ❑Stainless Steel ❑Other Grout Seal Depth r(1. ft ❑Neat Cement(94/h hub/5-/0 gal water) ❑Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed BY ❑Driller e ' mp Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level tt OR 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL ' WORKERS COMPENSATION LAWS. �J MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED ! U -i e'e TITLE !fix L( IEy' DATE rn 'Y! )12 t O S C IIL— tR N M N ,✓ DEPARTMENT U QE ONLY c� Application Accepted By `- Date r 5 Area Employee ID# ` c)0 Grout Inspection By Dat'l®- S ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS CC,3 C&T OF PIF-Co L_oCy --f70A1 Ot-tU t0�2 /�ClC H+Li &Gt'vS OCeQ �vEte. 7z, 0&_s7 d u-601",J c"v .,LsveC_7-0 usr ?9.0 CtU'6-: J (,7u, 4 1p, c—.1 71) r✓ Z 1 NLm- C3 - -to 1 LA-- GcL e--(-4.JZ>`c-,d +E E 7FA-G44 0-(&•.�T PE SC Received eck#/ Amount Permi/ Codes Info B s Remitted a Service Request# Invoice# Well ID# Ufa 9 EHD 43-02-006 .. WELL PUMP PERMIT 8/6/04