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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVIV-Ktt-UNUAtSLt rtKMII VALL LUZI ZfOS-/O%P1 ttUK lIINN5Yt'C I I'UN,5 tArIKtb T TLAK FRUM UAVE: 155ULD <br />JOB ADDRESS .4PES Or. L Ert. Ay .' """ _' 1" 9oa _.sT•r.w1 004 CA '17,6 1 <br />CROSS STREET„ I I I I I I APN I4 �J�•- ©3a •�O/ PARCEL SIZE IMAND USE APPLICATION # <br />OWNERNAME 5Toc.lCTahl ort N.*KC.t" 71a Sep a Igy <br />./`. �/ �l R�II[Z� PHONE 2�7 �� G��� <br />OWNER ADDRESS P*0 • 10 Ox p 81! �+ ! Q CITY/STA•TE/ZIP svoc ropq c -A <br />CONTRACTOR ^AdmAm G G-2 C Vi C e C PHON9p� q16 7 toa No <br />CONTRACTOR ADDRESS CV / S AMS A CITY/STATE/ZIP J t- lT� <br />SUBCONTRACTOR •„ we %I A"pjos ` PHONE `) TPS w ` , <br />SUBCONTRACTOR ADDRESS 336% r-4p5trALG A&. CITY/STATE/ZIP AA#la* CV/ U✓4r <br />LICENSE -A-57 C-61 D-09 Other NUMBER (010"7 EXPIRATION DATE II�3 O -sa q <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE - DomesticlPrivate - Irrigation/Agricultural - Industrial - Water Quality Monitoring ASO![ Sampling/Characterization <br />- Public Water System <br />If different from Owner: Water system Name on a ame or Phone Number <br />TYPE OF WORK - New Well -- Replacement Well Well Alteration/Modification - Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical 1# of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method - Mud Rotary - Air Rotary AAuger - Cable Tool - Push Point - Other A1' <br />Proposed Well Depth 10 ft Excavation _� in diameter - Open Bottom - Gravel Pack/Gravel Size A" in diameter <br />- Conductor Casing in diameter / ConductorCasing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched -,�'A -Steel - Plastic - Stainless Steel - OtherAIIA <br />Grout Seal Depth %O ft - Neat Cement (94 Ib bag/5-10 gal water) �f -" Sand Cement sack mix/7 gal water <br />- Bentonite (20% solids) - Other 8D"I A F46 TV ,r£ +a <br />Grout Placement Method *umped `Free Fall Other IrRetardant/Accelerator(name)_ <br />PEDESTAL Installed By - Driller - Pump Contractor - Other NI1T <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick in - Christy Box - Stove Pipe <br />PU- Submersible- Turbine - Other HP Pump'Set N ft Standing Water Level <br />MP 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 />MINIMUM 24 HOUR AD NNr,,E NOTICE REQUIRED FOR INSPECTIONS - PLEASE <br />� CALL (209) 953-7697 <br />SIGNED �l/� TITLE?r&%Lt� m�T�./ DATE 0110-9 1%6 lei <br />PO <br />. ••� Kid■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />IL �/ - <br />HEALTH <br />EHD 4366 WELL /PUMP PERMIT <br />4/30/12 <br />PE SC Received rjVj00F <br />Codes Info B Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice# WellID# <br />/ <br />�/ I <br />W )Servvicce�Re•�ueesstt# <br />W/ /v <br />EHD 4366 WELL /PUMP PERMIT <br />4/30/12 <br />