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41,10 <br />'PA <br />74A 10.13.01 - <br />/ <br />y` <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL ZUy V53-Tb'J/ FOR INSPEC`Ty/ION , VIKt5 7 T RFROM DATE ISSUED <br />7 �U <br />LA` <br />JOB ADDRESS �' f `1� "`{// 61TYIZ P <br />\\ /1 <br />CROSS STREET OSPITAL ROAD APN 067-200-01 PARCEL SIZE 321.8 LAND USE APPLICATION # <br />OWNER NAME JOHN OSPITAL Jn )1 t) `f aJc S CM C>5 I Tr PHONE 209-327-5071 <br />OWNERADDRESS 8493 SOUTHWORTH ROAD CtTv/STATE/ZIP VALLEY SPRINGS, CA 95252 <br />BRISKI WELL DRILLING CO INC <br />CONTRACTOR ADDRESS _ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 _. <br />C-61 D-09 <br />CITY/STATE/ZIP <br />PHONE 209-754-3394 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 9,3 �47 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDFQ USE Domestic/Private Xlrrigation/Agricultural Industrial Water Quality Monitoring Sal Sampling/Characterization <br />Public Water System <br />If diHerem from Owner Wailer z5ysterri Name Corilad Name or Pnone NumDer <br />TYPE OF WORK X New Well Replacement Well J Well Alteration/Modification Other <br />_ Monitoring Wells) # of wells J Soil of bonngs # of wrings <br />Bodng(s) Geotechnical ' <br />Out -Of -Service Well J Out -Of -Service Well Renewal Cross -Connection Repair <br />New rump _ rump r<eplacemem J rump ttepalr ttalse Welt Gasmg <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary X Air Rotary Auger Cable Toa Push Point Other <br />Proposed Well Depth 400 ft Excavation B in diameter X Open Bottom Gravel Pack/Gravel Size 3/8 x 1/4 in diameter <br />Conductor Casing iD in diameter / Conductor Casing Depth 20-50 ft <br />Well Casing Diameter 6-5/8 in Thickness/Gauge/ASTM Sched IBB x Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 ft Neat Cement (94 Ib bagl5-10 gal water) X Sand Cement 10 sack m/xl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped Free Fall Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By XDriller � Pump Contractor �� Other <br />Concrete Pedestal Dimensions: Width —L It Length ft Thick n Christy Box Stove Pipe <br />PUMP Submersible.. Turbine Other HP Pump Set ft Standing Water Level <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 />MIN MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 1 A b"L`-�' TITLE PRESIDENT DATE 9-11-17 <br />N <br />M <br />D <br />0 <br />mm <br />N <br />LUla <br />AL Hji4LTH <br />PECE v tv <br />SEP I g 7017 <br />JOA <br />PMtpR��M1� <br />DEPARTMENT USE ONLY <br />}' y l f 1 �—'s- � <br />Application Accepted By Date �' `/ Area Employee ID# <br />Grout Inspection By I Date 0 SPECIAL Well Permit <br />Pump Inspection By V Date 0 WAIVER R@C@IV@d <br />Soil Boring InsppesI n y (± e1 Date Constructed Well Depth It qy <br />COMMENTS �1 if Z' f r I � IZy I� L' i 1✓I r r � C �. 3 1 , ��M ��i <br />PE <br />Codes <br />Sc Received <br />Info By <br />Amount Permituest # l 9� <br />Remitted Date Service Re Invoice # Well ID# <br />y3i>�9 <br />Igc� <br />3�i7Z tUf �r ; "�S <br />A*Iq <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />