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.. jtio-a L kor q 121 111 W p t/ <br />`t0 <br />K, i <br />boIs K) <br />%h 1013-6y . <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-76f97 FOR INSPE(/CTION PIRES 1 Y RFROM DATE ISSUED <br />JOB ADDRESS <br />-2 7'70 i7 `-' <br />v f �'• CITYI7JP <br />CROSS STREET OSPITAL ROAD <br />APN 067-200-01 <br />PARCELSIZE 321'$ LAND USE APPLICATION# <br />OWNER NAME JOHN OSPITAL <br />; yl y) j� ��=k'�-q <br />�j T) -5j? jr Tr- PHONE 209-327-5071 <br />OWNER ADDRESS 8493 SOUTHWORTH ROAD <br />CITY/HTATTJ7JP VALLEY SPRINGS, CA 95252 <br />CONTRACTOR BRISKI WELL DRILLING CO INC <br />PHONE 209-754-3394 <br />CONTRACTOR ADDRESS <br />CITY/STATE21P <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATEZP <br />LICENSE XC -57 _ C-61 _: D-09 <br />J. Other <br />f, <br />NUMBER 9 `� �4 11EXPIRATION DATE 1(- •'�-' <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />WENDED USE _. Domestic/Private XlrTigation/Agricuttuml Industrial _ Water Quality Monitoring Sal Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Nam Contact Name or Phone um r <br />TYPE OF WORK X New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Sall Boring(s) * of borings Geotechnical • of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal _ Cross -Connection Repair <br />. New Pum Pump Replacement _ Pump Repair Raise Well Casing <br />WELL. CONSTRUCTION <br />Drilling Method Mud Rotary X Air Rotary _ Auger . Cable Toa . Push Point _ Other <br />Proposed Well Depth 400 it Excavation 8 in diameter x Open Bottom Gravel Pack/Gravei Size 3/8 X 1/4 in diameter <br />. Conductor Casing 10 in diameter / Conductor Casing Depth 20-50 ft <br />Well Casing Diameter 6-5/8 in Thickness/Gauge/ASTM Sched .188 x Steel - Plastic Stainless Steel Other <br />Grout Seal Depth 50 ft Neat Cement (941b bag'5.10 gal water) X Sand Cement 10 sack mixl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped -: Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By )(Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Lengthft Thick in Christy Box _. Stove Pipe <br />PUMP )(Submersible._ Turbine Other HP Pump Set ft Standing Water Levet � ft <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 />f <br />SIGNED 1 /g TITLE PRESIDENT DATE 9-11-17 <br />_LA <br />D <br />E <br />W.. <br />CEIVD <br />P' 3 zon <br />wvfcfv IAL HE <br />IIT/SERV}CFS TH <br />RErME <br />CEIVED <br />SEP 19 2 <br />J04Q <br />WAI <br />HRO MFCOU" <br />1}' OfPAP kEAl <br />DEPARTMENT USE rONLY <br />Application Accepted By Date <br />/ �/ - Area Employee ID# 6Se'C' �G <br />Grout Inspection By Date I dj 3+ 117 ❑ SPECIAL Well Permit <br />Pump Inspection By Data n WAIVER Received <br />Soil Boring In esti n y N Date Constructed Well Depth It <br />�+ - °�z <br />COMMENTS (' ' _ 7 <br />PE <br />Codes <br />Sc Received <br />Info B <br />Amount <br />Date Remitted <br />Permit/ 9h <br />Service R uest# Invoice # Well ID# <br />43G9 <br />1gta <br />397- `� 4 <br />I,jpm- 733 <br />© v 100 3-2- <br />G <br />EHD 43-06 <br />4130/12 <br />WELL /PUMP PERMIT <br />