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s <br />V <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />PION-MLI-UNUAULL rLK{{Ml l <br />GALL (AUV) `J0J-/Otf f FOR INSPECTIONS 1Kt5 l YEAR FROM <br />JOB ADDRESS V oGtp3 ', . <br />1 <br />L l i S <br />�tAY <br />1/UA�JTE�'IISSUED <br />+ <br />CITY/ZIP -F--- �1/L� q��J(/� <br />`C <br />CROSS STREET 0 D\1 Vk--- �j . <br />A'PN\�� <br />SIZELAND USE APPLICATION # <br />OWNER NAME (t �[�Q. <br />� <br />_- �]-����- <br />h (_�P/AyRCEL <br />I G A. , I M�VIVI L—TfONE <br />+ <br />OWNER ADDRESS �1-�'1�' <br />` S 1 <br />g CITTY'/S_TATEILP �5 <br />CONTRACTOR (.�).`f+��2�U_.lew^/iWi <br />/l, <br />Lk F�r�(J��C�JAI <br />L �'1 c G(i)t <br />G1Q,�. LI �`L— 1'%Lj I& 25 (ITS` <br />CONTRACTOR ADDRESS L-�i. 7 �1 y C'r'n .r <br />/ 1P,HOONNEEO�`D <br />F'Cx` CITY/STATE/LP <br />SUBCONTRACTOR V-'1' <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/ST—A1EE <br />TIILP <br />LICENSE ?.-57 :: C-81 D-09 Other NUMBER 1 1 EXPIRATION DATE �L� <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring I i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: a er Systern Narre uontaCtNarhe or Phone urn er <br />TYPE OF WORK f New Well r Replacement Well i Well Alteration/Modification I Other <br />f MonitoringWell(s) #of wells r SoilBoring(s) #of borings I, Geotechnical #of borings <br />!�I/ Out -Of -Service Well , Out -Of -Service Well Renewal Cross -Connection Repair <br />�yVeW Pump i Pump Replacement Pump Repair Raise Well Casina <br />Drilling Method r Mud Rotary i Air Rotary r Auger Cable Tool r Push Point I Other <br />Proposed Well Depth ft Excavation in diameter r Open Bottom I- Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad r Steel r Plastic I Stainless Steel i Other <br />Grout Seal Depth ft I i Neat Cement (941b bag/5-10 gal water) r Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) F Other <br />Grout Placement Method I 1 Pumped I Free Fall r Other r Retardant / Accelerator (name) <br />PEDESTAL Installed By r Driller n Pump Contractor r Other <br />I Concrete Pedestal r Dimensions: Width ft Length ft Thick in i Christy Box i Stove Pipe <br />PUMP SubmersibleI Turbine I I Other HP Pump Set I '5ft Standing Water Levelft <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 />JIIMNIMUM 24 HO1,UIZ ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9P3-7 7 <br />SIGNED 1ALMbTITLE � � > DATE Lk %—t ` <br />N <br />D <br />O <br />v <br />N <br />N <br />CIV <br />1,y 0 8 2017 <br />RON?MENTAL HEALTH <br />ERNIIUSEMACES <br />RF FENT <br />AW Io 0 <br />N1y 201/ <br />J <br />f,yy�Rp <br />54trND tiM. <br />DEPARTMENT U E ONLY ������ <br />Application Accepted By Date Area�jj(t <br />�� Employee ID#�pD�Ul.b S <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Data ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30112 <br />