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-� WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3Me FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS ��3� !✓'esf L:-t tee.i CITY/ZIP 1 � E4 y <br /> ,( S-6 USE APPLICATION# b� <br /> CROSS STREET �-�r'S^..+� /` APN ;3.S3—Lr v-3 O PARCEL SIZE LAND <br /> p (Za9) 833-99ys <br /> . Bi It PHONE n/-'.�o<+p <br /> OWNER NAME p ' <br /> i OWNER ADDRESS !J y 33p O �Q Lrt1e. �t�+� CrfY/STATPJZIP �r_� 95-3oy <br /> CONTRACTOR b✓Gf+-' �ewff .s-' Fle _ PHONE <br /> CONTRACrOR ADDRESS P U' x I'S`J - CITY/STATEMP Trn c GA 95 37 8 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other i0 NUMBER 7 3 9'938 $xputATI6N DATi D8 h i o <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USP• Iomcsticftvatc ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System ontact ame or one um r <br /> Irditttreat from LAv : Wow ystem am <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other s oibor ng <br /> 13 Monitoring Wells) #of wells [2 Soil Boring(s) s of borings 13 Geotechnical <br /> ❑Out-Of-Service Well ❑Out-0f--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 13 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing- in diameter / Conductor Casing Depth ft (/1 <br /> Well Casing Diameter_in ThicknesslGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other c"P <br /> Grout Seal Depth It ❑Neat Cement(94/b bag 15-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20`/o solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PErim <br /> PEDESTAL Installed By 13E3Driller Pump Contractor ❑ Other tl-hick in ❑Christy Box 13Stove Pipe a <br /> ❑Concrete Pedestal Dimensions:Width ft Length b <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I !HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ICENSE IS <br /> CURRENT AND ACTIVE ORDINANCES, <br /> THE CALIFORNIA CONTRACTORS STATE LAWS.AND RULES AND LICENSE BOARD AND THTIONS. I ALSO AT t AM IAT N COMPLIANCEREQUIRED LWITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ITLE �� . T ^•�' 9r DATE o33 <br /> �4 Q <br /> i <br /> I <br /> E <br /> 0. <br /> x <br /> 0o e <br /> ._._.,. - D <br /> ....,, EPA RT'MEN'T USE�ONL V.... � S <br /> 1 Date C3 'C Area EmployeeID# <br /> Application Accepted By <br /> t Grout Inspection By <br /> ,pate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date C3 WAIVER Received <br /> Constructed Well th tY <br /> COMMENTS <br /> PE SC Received Cbec Amount Perm It Invoice# Well IDN <br /> Codes Info B Cash Remitted Dau Service R uest# <br /> 3.F 0-0 0 / <br /> WELL PUMP PERMIT <br /> ESLD 43-024W <br /> 1/27/2005 <br />