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3 <br />' 19764 � <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />1JO8ADDRESS 15420 E. ST. RT. 4 CITY/ZIP STOCKTON 95215 <br />ICROSS STREET HOLLENBECK RD. APNI S3-1 —001 _PARCELSIZE ' () LANDUSEAPPLIcATION# <br />OWNER NAME TOGNINBLI FARMSJl /T PHONE 601-2069 <br />OWNER ADDRESS 145500 HWY 4 CITY/STATE/Z)P S TOCKTON CA 95215 <br />CONTRACTOR __pe] to pWgR STC1CJK= ARMATTIRE & MQ QR WORES E"Q- 209-466- 625 <br />CONTRACTORADDRESS 646 S. California Street CITYISTATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 X C-61 <br />0 D-09 <br />PHONE <br />CITY f ST AiEIZ\P <br />Other NUMBER 724778 EXPIRATIONDATE 08/ <br />GEOGRAPHICAL INFORMATION: Coordinates X �r <br />Township Range Section <br />INTENDED USE G DomePublic i atter yste Irrigation/Agricultural C Industrial O Water Quality Monitoring O Soil Sampling/Characterization <br />G Public Water System <br />If different from Ovmer: a ter ys em amo <br />I on a ame or one um ter <br />TYPE OF WORK New Well 0 Replacement Well „ Well Alteration/Modirrcatlon 0 Other <br />G Monitoring Watl(s) # of wells G Soil Soring(s) # of borings # 0(bo <br />Our -Of -Service Well z u' Geotechnical <br />L Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />FDthcC New Pum C Pum Re lacemeni um Repair p RECE/VE0 <br />od' <br />ION O Raise Well CasingI1 <br />C Mud Rotary Air Rotary 0 Auger n Cable Tool 0 Push Point 0 Other D — <br />Depth P It Excavationin diameter 0 Open Bottom 0 Gravel Pack/Gravel SizeH <br />C Conductor Casing in diameter I Conductor Casing Depth Ftlr <br />Well Casing Diameter , in Thickness/Gauge/ASTM Sched ft <br />Grout Seal De th 0 Steel D Plastic O Stainless Steel O Other <br />f p ft C Neat Cement (94 Ib bag/5.10 gal water) C Sand Cement <br />1 G Bentonite (20% solids) O Other sack mixR gal water <br />Grout Placement Method 0 Pumped I <br />0 Free Fail ^Other 1 <br />0 Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller Q Pump Contractor O Other <br />C Concrete Pedestal Dimensions: Width R Len th <br />9 h Thick in O Christy Box 0 Stove Ripe <br />PUMP ;, Submersible rbine C Other___ <br />HP Pump Setft Standing Water Level 1 <br />I HEREBY CERTIFY THAT I HAVE PREPARED Tft <br />HIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I <br />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 1 AM IN COMPLIANCE WITH ALL <br />SIGNED WORKERS COMPENSATION­LAWS— <br />MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO DATE9/ 2 5/ 2 01 7 <br />1 <br />NOTE: <br />PUMP SET & STANDING W, <br />IS UNKNOWN UNTIL THE JOB IS DONE <br />DEPARTMENT USE ONLY <br />Application Accepted <br />Grout inspection By Date <br />Pump inspection By Date <br />� n <br />1 <br />Soil Boring Inspection By Date <br />COMMENTS Date <br />'' <br />Codes <br />�� Received l� <br />Info 13 <br />y3� <br />iii'---------a-- <br />vs o ► z 9 <br />EHD 43.06 <br />8/04/oa <br />Amount <br />le7mitted Date <br />7%3 / 7 <br />4, <br />Area 19 SEmployee ID#_AJ3�ft1 G� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Invoice # I Well ID# <br />WELL /PUMP PERMIT <br />W, <br />m <br />m <br />0 <br />0 <br />m <br />m <br />