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c--------� ` 7> WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALI n DEPARTMENT 304 E WEBER AvE 3a°FL-STOCKTON CA 95202-(209)469-3420 NON-REFUNDABLE PERMIT r� CALL 209)953-769�7/FOR INSPECI IONS E{XPIRESt/I YEAR FROM D JOB ADDRESS 1,, /� ��O�� •� �t/y�•�1' CrryinP tI">'d e-/��'/n U r a CROSS STREET 4 O(,..K A-sv 4—e3 'APN/an�sa/-300 /�—3 0l0-LJ`J PARCEL SIZE l D'QLAND USE APPLICATION#__7 gg V 1= OWNER NAME `✓E LF z lT pt itf,' L 'NI�.PHONE (ZO C7l ybC��17tL.iN.(! N�I�o(' OWNERADDRESS /r-91C.G/-- 2 r.1—Yt ft„I ,/./ CITY/STATE/ZIP OrS� p�OQ / CONTRACTOR o . D I O< ICG v LJIZi V�L�-4y- PHONE O�O 63 E T HEALTH CONTRACTOR ADDRESS S 7 �J 'r CITY/STATE/71P�' / �P 2�� VICES SUBCONTRACTOR �� 7 PHONHO/Iyg—qI r -39(- SUBCONTRACTOR ADDRESS CrrY/STAT FfZIP J LICENSE ❑C-57 ❑Cfil ❑D-09 BSOther� NUMBER N/f' EXPIRATION DATE A A GEOGIwPHICAL INFORMATION: Coordinates Xt7 Z d Y 1 q /�s Township3d Range�(� Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial i2rWater Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If diff t from ower. Cmact Name or Phone Num TYPE OF WORK ew Well ❑RAplacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Wel1s)_CL #of bori°g #of b°a gs . ❑Geotechnical ❑Well Deswcti(( /N OV W44t,WJTut-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pu Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drifting Method "Id R ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other G' Proposed Well Depth ft Excavation in diameter ❑Open Bottom eGravel Pack/Gravel Siu — in diameter Q I ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diametere2 �inT, Thickness/Gauge/ASTM Sched y�Cti tgb 13 Steel 0tiastic 13 Stainless Steel ❑Other Grout Seal Depth�,F�p(JOr.Tt ❑Neat Cement(94 lb bag l5-10 gal water) ❑Sand Cement sack mix/7 gal water (y, ❑Bentonite(20%solids) Til Mang�6Macturer Spec%solids % Name�l�j- 60/4— ❑Specs on File ❑Specs Submitted B' � 11 Grout Placement Method �umped ❑Free Fall Ll UtherN'"" ❑Retardant/Accelerator(name) ' PEDESTAL Installed By til-rifler ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box 13�<tove Pipe POMP 0 Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL V WORKERS COMPENSATION LAWS. if ' �IUR HOUR ADVANCE tiOTICrE-REQUIRED FOR INSPECTIONS r41 SIGNED aZ �f-. i\/ TITLE Il DATE � L1- 0 J b��f6 EN-T Zmcz IVED 0 2005 A O' IN COUNTY VI NMENTAL T EPARTMENT wey"�'il t RTMENT USE ONLY ub Application Accepted By Date �Q os Area Employee ID# +rte Grout Inspection ' ' Date__` %�Q� C C ❑ SPECIAL,Well Permit Pump Inspection By Date ❑ WAIVER Received C= Destruction Inspection By Date Constructed Well Depth It, COMMENTS f W z IA7 t VL t•1( L D r r j I►a T t►J ar Pr- 6t-jlY �A tr (( sc R CYw► IKS ti o' Jl3 SCALY.(� sT -[r,1 (�., (Ie,4 PE SC Received Check#/ Amount Permit/ Codes Into B as emitted Dale Servicc Request# Invoice# Well ID# `f3-65 �52- 7 (0 4-I U-)Q MIIII�w LOLM EHD4M24)06 ,e f'� � ��'..(�'��C.�/>(C(L-/ - / �S'��4,37—&P,3 WELL PIMP PLKN111 N/Wor s.rco . c� �a-T — Baas Ji>v:v tiA .4G�r�..�f 4s.3-�vc �� /1'!�i ) i,n /14-1")