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T h KtwA � ulr/i 7 - z1-1-7 rr)`�2i^ <br />WELL/PUMP PERMIT <br />SAN JOAQWN CQUftTir ENVIRONME.NrAL HEALTH DEPARTMENT 1868 EAST HAYEI.TON AVENUE-$TccxTON CA 99208 - (209) 4GS-3420 <br />NON-REFUNDABLE PERMIT CALL 208 853-7687 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB AoDRESS 7740 ANDREA AVE. q_ ._ CnYMP�Ci_KON.9520T <br />CROWSWE r RIVARA RD. APNd7?' 7�i%'?/�PARa4$a, ,� LANpUaeAPPucAnoNs <br />OWNER NAME KASEY FOLEY �� ,. �LGLILi'�IO � �PIIO 09.839.6501 <br />OMERAOIR= 7740 ANDREA AVE. CITY/sTATEIaP STOCKTON, CA. 95207 <br />CONTRACTOR N & $ IRRIGATION. INC PHoNe 209.59,9.345$ <br />CONTRACTORADDRESS 2115 W. MAIN STREET (xryfgTAre!(IP fR PdN C�. 95366 <br />SuacorMACTOR PHONE <br />SUBCONTRACTORA00ft 5 Crryl$TAYr44P <br />UceNse ❑ C-157 D C-61 a D -M X0ther C 10 NUMBER X2732`- Eywm nom DATE 01/31/19 <br />CaOaRAPFacAr-1NPORm TION: Coordlnatas X Y TownSpip _ Range section_ <br />Itr1'Emity LLm DOmesGclPdvate IrrlgatlonlAgriculnrral Q industrial ❑ Water Quality Monitoring ❑ Soil SamplinglChamcterizadon <br />Public WaterSystem <br />It cUff Chum Owner: o <br />TYaa OF WORK - New well = Replacemont Wall C Wdl MoraboWodific4on C ofte <br />m Monitoring Wells) d Of vANS U Sol] Boflng(s) f of be"r'oa U Geotethnlcsl xar b"a <br />Out-014ervlce Well ❑ Out-Of-Sarvitc Well Renewal 0 Cross- Connection Repair <br />- .,.... ,..__ 1F n n, — n... — n M.a-., u,.." r.... -- <br />Drilling Method - Mud Rotary - Air Rotary - Augor n Cable Tool rl Push Point r Otner <br />Proposed Well Depth ft Excavation _ in diameter 7 Open Bottom 7 Gravel Paws ravw Size_ in diameter <br />_ Conductor C"rig In diameter ! Conductor Casing DcPth ft <br />Well Casing Diameter In ThickneWGeugrJASTM Med :I Steel C Pismo ❑ Stainless Steal D Other <br />Grout Saal Depth ft U Neat Cement (94 !L bag15-10 gal water) a $and Cement aarxr mb(17 gal water <br />-- Bentonite (201A solids) ❑ Other <br />G"HAPlacementMethod ❑ Pumped o Free Fall (3 OBier D Retardant) Accelerator (name) <br />PEDESTAL Installed By " OrMer U Pump Contn=r Other <br />- Concrete Pedestal-Dlmansionx: Width ft Length _ _ _ n Thick In - Christy Box -i Stove Pipe <br />a $uhmersibleC Turbine C Other_ HP—__I_ Pump $aL__fia it Stendiny WatertaveI __2B _,_ It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN <br />JOA UIN COUNTY ORDINANCES, STATE LAWS, AND RULE$ AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED uCENSE IS <br />C C_N7 AND A E WITH THE 50RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />W OMPE S TI�LA�MUA N E I�EQUIREO FOR INSPEGTIONS-PLEASE GALL. (299) 9SS»7697 <br />SIGNED 1]aYE ...I-� <br />EPA TMENT $E ntLY <br />Application Attepted By Dahl Area � "[- Employee IDD` <br />Grout Inspection By _ Date ❑ SPECIAL We11 Permit <br />Pump Inspection By <br />' Date 0 WAIVER Received <br />Soil Baring ins n 8y _ ^� ate .. CorAitrucl Well pih ft <br />COMMENTS hl tLiti�l LfI ^ /�LLi9t7� 9 gJJ ta, i.a <br />fr <br />PE SC Received Checlaw <br />Codes Info Cash <br />Amount <br />Remltmd <br />Date <br />Satvke <br />r <br />InvoiceWe111U11 <br />� <br />B13" YJELL/PUMP PERMIT <br />4MM2 <br />