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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)460-3420 <br /> NUN-REFUNDABLE PERMIT CALL, 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JoBADDRESS GI CrrY2y�,e <br /> Iva/ 1P c /L--�57�� ^ <br /> L�fMelly Rg( ,n_ Q <br /> CROSS STREET_- APN �i'S lkZt9— � PARCELSIZE IISE APPLICATION(1 _ pa <br /> OWNER NAME �{Nt� ER a ���� ����� �'aPH�OrNE 7�0 <br /> OWNERADDRES.S T `T DoL1-I/ I LI. bQ CIrv/STATFILIP Gip ,risq/V6 D q�•` <br /> COYrRACTOR 0041 /07Loa <br /> y7\&s e l &Q, (1---�I�.1.IA `J�C4Q11(GF 1IYC PHO'N'E F--,b.'/S W6-9113 <br /> YT- <br /> (1 e o_/ <br /> CONTRACTOR ADDRESS al(/ ,�`N/t I�t� yam!/ -- CITV/STATE/ZIP`'J �Y/�IVI e • �s 5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS _ _ Cn'V/STATE/ZIP <br /> LICENSE G57 ❑C-61 ❑U-D9 ❑Other NCMBER f 6 E%PIRAMN DATE [93-3/-09 <br /> GEOGRAPHICAL INFORMATION: Coordinates X V Township— Range Seetioa_ <br /> IYrTNDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactcrization <br /> ■Public Water System S fft y t C r- S'V-,4 in.ta er DOER11 C Moet « ne Numbcr <br /> If diRer<m from Owner. ua Syt�rt+ <br /> TYPE OF WORK !New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other - <br /> ❑Monitoring Well(s)_ p of wells ❑Soil Borings) a orbo"na' ❑Geotechnical a ofWriag, <br /> ❑out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connectiun Repair <br /> ❑New Flump ❑Pump Replacement ❑Pump K it <br /> �'F.LL CONSTRUCTION <br /> Drilling Method III Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other O <br /> Proposed Well 1 Dtpth 066—R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sire _in diameter <br /> �t j'A'Ads\ ❑Conductor Casing_-_ in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter jCin ThickncWGauge/ASTM Schell !3 1t,__ IlSteel ❑Plastic ❑Stainless Steel ❑Other /*a <br /> Ata / Grout Seal Depth ;&/) —ft ■Neal Cement(94 1b bag 13-10gal»MCr) ❑Sand Cement sack mix/7 gal water "J <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Plaeement Method M Pumped ❑Free Fall ❑Other _ ❑Retardant/Accelerator(name)_-,. <br /> PF.DF_STAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions'Width R Length R Thick in ❑Christy Bos ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbinc ❑Other IIP Pump Set it Standing Water Level ft <br /> 1 HEREBY CERTII•-Y THAT I 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 MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 224 HOUR ADVANCE NOTICEEQU RED FOR INSPECTIONS <br /> TITLE ` DATE. Q� <br /> 14 <br /> ULNIR N ETA <br /> DEPAR NT USE ONLY <br /> pplicauonAccepted By�T"L �/1iJrt.� __ are_--t;,/���� -- Area Employee ION -V�O <br /> Grout Inspection By - Uate�A r� ❑ SPECIAL Well Permit <br /> Pump Inspection By 17 Slfic-er __ ❑ WAIVER Received <br /> Constructed Well Depth JJ <br /> CO�pMFNTS (% {!• hdlt' '1�_NOf r l hIkkM,r�P� �yJI. LL <br /> /MI I✓I g I 0 � 7� G <br /> p¢ PE Sc ReedvedAmount Per U Invoke# Well IDN <br /> Codas Into By Cash Remitted to Service Re uest 0 <br /> 685 IVY 38D <br /> !e _ <br />