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a►S_'16./ <br />"V dr A WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE VERMMIT C p�,�GALL -LU11y53-/bUt FOR INSPECTIONS �tArIIK(�CJ "I TT EAR FROM UAIE 15SUEU <br />JOB ADDRESS a660 S �' A04_- f6Uy �-J CITY/ZIP �K{J�J G 7 <br />jJ ,- LS3 0LA0 0 r fvl(a. to l <br />CROSS STREET �r 5 U APN L`5:�(rOLA PARCEL SIZE io LAND USE APPLICATION # <br />OWNER NAME CbV\tV<.A WSW U.oiY D1S� AU, ^PHONE (CA -LS) (nnif 1"�iGl�liZ <br />OWNER ADDRESS � � � :iCV1C,(t'! tw e CITY/STATE/ZIP Ci Lou''l Cl Ll� 'fVI� LO <br />CONTRACTOR Pft=vq*P;ft't-\ C . epa ua PHONE (7-2) - �D O ) <br />CONTRACTOR ADDRESS [� 1 Y1G�US t P 1 C4� �J.i JILL <br />SUBCONTRACTOR i3 l i <br />SUBCONTRACTOR ADDRESS <br />LICENSE /C-57 C-61 D-og Other <br />CITY/STATE/ZIP k,(] ,n, l A 06 LA O <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER (11� O "Li EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X �1 . (o5'11 Y a1 m-) 0 5 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 Uontact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />Well Alteration/Modification <br />,/Soil Boring(s) <br />Out -Of -Service Well Renewal <br />Other <br /># of borings Geotechnical <br />Cross -Connection Repair <br /># of borings <br />New rump rump Replacement rump Repair Raise vveii t;asing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary ✓Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation CL'" in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Oeat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) X QthPr Sig�— <br />Grout Placement Method Pumped Free Fall X Other , Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP 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 IM M 24/ HO VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76�9J7 <br />SIGNED ( TITL JL4 f !/i:�M4,CJ✓ DATE <br />EP RTMENT U E N L Y <br />Application Accepted By 4�VDate <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Area 1540 Employee ID#EJ&L�U' <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />A <br />m <br />D <br />0 <br />v <br />m <br />m <br />y <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />ec <br />s <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />