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<br />CITY/STATE/ZIP e-ist 9 5 2 7 e <br /> <br />PHONE :si3uaV3.LIS \ <br />Alt WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" Pi. - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES"! YEAR FROM DATE ISSUED <br />JOB ADDRESS 2 & 1-1 c/ CITY/ZIP rr‹,c, y 47 5' '3 y <br />CROSS STREET f1 (4.APN t '/- 7 - PARCEL SIZE '11 '9 '7 LAND USE APPLICATION <br />L? - — OWNER NAME PHONE {? c/) <br />OWNER ADDRESS 7 0 tr 3 1 ki.,-\it-x 4)6 4% J CITY/STATE/ZIP ç- j'.,- <br />CONTRACTOR eic,CI,05. T Je" fe, Se PHONE ( 7 .yj 5 • ze / <br />CONTRACTOR ADDRESS C 0 ). (5-r <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE 0 C-57 0 C-6 i 0 D-09 9Y-Othcr 02/ A NUMBER 7 3 3 I EXPIRATION DATE ert1/4/1* <br />GEOGRAPHICAL INPORmATioN: Coordinates X V Township Range Section <br />JNTENDED USE mestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water Sys tem <br />!I &ft-trent from ner. Water System Name Contact Name orl5TOite Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil B <br />0 o f borings <br />oring(s) 0 Ccotechnical # Ofberings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement jig Pump Rcpair <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack / Gravel Size in diameter <br />El Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/GaugelASTM Scheid 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth f1 C Neat Cement (94 lb bag /5-JO gril water) 0 Sand Cement sock mix / 7 gal water <br />0 Bentonite (700/, solids) 0 Manufacturer Spec % solids % Name 0 Specs on File 0 Specs Submitted <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal Dimensions: Width ft Length 11 Thick in 0 Christy Box 0 Stove Pipe <br />PUMP qt-Sliblnersible 0 Turbine 0 Other HP I. C Pump Set 7 ft Standing Water Level -2—C' <br />I HEREBY CERTIFY 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 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 />SIGNED <br />IN17.1HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS NI <br />--TITLE At "--,7 47 1. • C DATE / Vo 7 <br />t., 4 <br />ArsSE <br />(M EN ' ,El \ft,r_-) <br />JAI I 9 t5117 <br />l-L7J10 (X)N-1Y _ VlizilDNMENTA <br />H EllAirMENf <br />53. <br />Oc. <br />41141" 4,41,;.+7c <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />DEPARTMENT USE ONLY <br />Date Area Employee !De? .347 <br />0 SPECIAL Well Permit <br />0 WAIVER Received <br />COMMENTS <br />Constructed Well7 b <br />PE <br />Codes <br />SC <br />Info By <br />Received(C—becldr_21,—./ <br />_r _ash <br />Amount Dote <br />Permit/ <br />Service Request # Invoice # Well ID# <br />?. ':: (.)50 71,L 13.-o -4_ <br />?emitted <br />- :cc, ,,-.) 111,101 'AM' P-f (1 q Vf 20 0 ,2 704:'0 <br />D 41-02-006 WELL PUMP PERMIT <br />005