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PA <br />RE' <br />OCT 2 <br />HEALTH <br />14921IWl111l1i1l,4NMI <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209)j953--7697 FOR INSPECTIONS EXPIRES 1 YEAR FROOM\�DATE <br />ISSUED <br />JOB ADDRESS _ 7 � pQ R o CITY/ZIP 43TO tr Th1� <br />CROSS STREET04 APN 19� 1 �� �'` PARCEL SIZE 7)1" LAND USE APPLICATION # <br />OWNER NAME S• <br />Ja f IrPHONE <br />�• �\ ` � , Cr f�-y I VQ^ J�7+3yQ <br />OWNER ADDRESS A �w `l �� Q� �"^'� /Y.V A CITY/STATE/ZIP r / f'y' o^t <A- !/^'7 % 3 7 <br />CONTRACTOR /Tly�r/■CL ��T{�=Q �'/�^/)-/ IJA/��f�SiM1� J� % � L• (PHONE rZt S - �b 7 -1 �y <br />CONTRACTOR ADDRESS .7 •/`J� Mac ry �T �/ CITY/STATE/ZIP J T'O CK'V A /- III -w? <br />V9 5 Z� 7 <br />SUBCONTRACTOR � V O 7 sykaf k1 C fit 9 �n� �l ��q4,N PHONE ! 91% — 7 I I - ? J <br />SUBCONTRACTOR ADDRESS 3 31A � F I -P Z 5f 1 !'� 9' * CITY/STATE/ZIPj&,i I� <br />LICENSE xC-57 C-61 D-09 Other NUMBER 68a Z -7 EXPIRATION <br />N <br />D <br />A <br />N <br />r,4 Z -F1 4F719 7— <br />la 17-01711 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone um r <br />TYPE OF WORK New Well - Replacement Well Well Alteration/Modfication%Other (s FO I z IL�N 11 EN1 P*Nii6 <br />Monitoring Well(s) # of wells Soil Boring(s) # or or_irgs *eotechnical 4# of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New PumD PumD Replacement PumD Repair Raise Well Casina <br />Drilling Method rV V u Rotary Air Rotary Auger Cable Tool Push Point X Other 1401/ O W S k -t tM Avcyr <br />Proposed Well �ft Excavation 48 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conduct Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter* in Thickness/Gauge/ASTM Sched �r Steel Plastic Stainless Steel Other A11114Grout Seal Depth A ft Neat Ce t (94 /b bag/5-10 gal water)) r� Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) %Other r0 <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) AfM <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP WIA Submersible Turbine Other HP Pump Set ft Standing Water Level 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 />MI IMUM 24-HOUR <br />ADVANCE NOTICE REQUIRED FO%IINSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED � 1 �`J �--- ._ TITLE �I1� \��r �ANA*G"'t/' DATE 11.) 7-1 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />Date <br />M <br />X <br />�< <br />� <br />O <br />�z <br />01 Z <br />� -i <br />S r' - <br />C7 2 <br />m <br />Cn <br />Area'���1CSV <br />Employee ID#�I <br />I SPECIAL Well Permit <br />L WAIVER Received %, I <br />Constructed Well Depth r `� (V4 ft 7 <br />A, ! ,. r• l rl _ '7 <br />PE SC <br />Codes Info <br />Received hec <br />B ash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest <br />so <br />3� <br />3 `� �' 23 <br />' �� <br />EH D 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />X <br />M <br />0 <br />M <br />