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I <br /> d tl <br /> � r <br /> 1 WELL 1 PUMP PERMIT <br /> SAN JOAQlI1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ave 3"°FL-$TOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-707 FOR.h'SPECTION, EXPIRES 1 YEAR FROMsDATE ISSUED <br /> 5z <br /> Jos ADDRESS Calimvrna Road -- _ CITY/ZIP <br /> S cxosssTREET Woodson Road APry b — Oilo--7 PARCELstzE apprOx.25 <br /> Galt .joint Unified School District PHONE(209) 745-3094 <br /> OWNER NAME /� C+ I <br /> OwNER ADDRESS 417 C Street, Ste. B CITYISTATEJZIP Galt CA 95632 <br /> CONTRACTOR Earth Systems Pacific PHONE <br /> (805) 544-3276 ' <br /> j 93401 <br /> CONTRAcTORADDRE.4378 Santa Fe Road CI7Y/STATE1zIPSan Luis Obispo, <br /> SvncoNTRAc OA PC '-Exploration PHONE 916 434-4200 <br /> SUBCONTRACTOR ADDRESS 3883 Cincinnati Ave. CITYtSTATEIZH`4`0 Ckl iri, CA 95765 <br /> Y. 8265556 8-31-OS <br /> LICENSE �C-Sl ❑C-6l ❑D-D9 ❑Other NUMBE - EXP1AATiON➢nTE _ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township— Range Section �. <br /> INTENDED USE ❑Domestic/Private ❑IrrigationlAgricultural ❑industrial Vater 65y oni.ri 'Sail argp r6cten�'ratiorn <br /> ❑Public Water System <br /> N enr cNa ? l <br /> lfdfff rent fmm Owner'. - eter ystnn Nawc <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlteratiordModification <br /> I( ❑Test Hole <br /> ❑Other <br /> ❑Monitoring wells) mhof—IN X7SoilBorin 5 29 Peym[ ap(ha a ' lvu t 1q <br /> ❑Well Destruction ❑Out-Of-Service Well 1�� p►•u�t�O1fY-Ste v,,e Wcl1 Renefwal <br /> 'I DNewPu C3 Pump Replacement ❑Pum Re air 9Yar Qt[ atsn - late r <br /> it WELL CONSTRUCTION ' r+ <br /> 'I Drilling Method ❑Mud Rotary [3 Air Rotary D[Aug'lr ❑Cable Tool ❑Pus�ife I ?`m other%1� 1'1 A a���1 rl(}_.• lZ� <br /> Proposed Well Depth 5-50 ft Excavation 8 in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel 11Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 ga!water) ❑Sand Cement sack mu 1 T gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids,% Name ❑Specs on File ❑Specs Submitted <br /> II Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) ' <br /> f <br /> PEDESTAL installed BY ❑Driller ❑Pump Contractor ❑Other <br />� Q Concrete Pedestal Dimensions: Width`ALengthf Ft Thick in ❑Christy Bax Q Stove Pipe <br /> PUMP ❑Submersible Cl Turbine 0 Other HP Pump Set ft Standing Water Level ft <br /> EL r40 Open am <br /> ❑ 0 Other <br /> it, er Tot ep ft Depth ❑ g t from _ft <br /> t c. <br /> ling Mat i at Ce 4 1 15-109a arerJ ❑San amen[ 7 gal er ❑ nto Pell <br /> Ben tl 0% id anufacw Spec%solids a son e ed C tLFi <br /> PI enl t d P ree Fall ❑OtherP� Ytt"LS S <br /> o ate ush on C ft below grade Com to E ting Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THI APPLICATION WORK DONE IN A RD CE WIT <br /> i JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 /> II <br /> 1N I>.,i! 411OuR. ovANceNoTreF.R>✓QcrReDFOR INSPECTIONS <br /> -TULE Vire President <br /> � 1 <br /> SIGNED DATE <br /> Ii <br /> k <br /> w 1 <br /> t <br /> i <br /> I7 I <br /> ` F . <br /> 1 <br /> 1 <br /> i <br /> � I <br /> i <br /> _ DEPARTMENT USE ONLY <br /> Application Actepted By Date Area Employee IDk <br /> Grout Inspection By Date ❑ SPECIAL W¢1E Per ! <br /> E] WAIVERReceived <br /> "J� <br /> Pump Inspection By <br /> Date 'r <br /> Destruction]nspection BY Date Constructed Well Depth ft <br /> COMMENTS <br /> PE $C Amount Cbec Received Date PermiO Invoice 0 Well IDN <br /> Codes Info Remitted ash By Service Re Best N <br /> Sa 54 <br /> 4 i <br /> EHD 43-02-006 ,.. y - Mosler Wstcr Well Pc It.dm <br /> i 8/2012003 <br /> 4 <br /> II <br /> I <br />