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A' -_ s <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS °RJ/I1 COO W-S.L '4 �_ 1z L/C4-( ?!j CITY/ZIP /z�G� (!,x y,5.3)`7 <br />CROSS STREET• A.-> E"j •' APN X0? -27c' , `PAARCELLSIZE'3'34AND USE APPLICATION# �yy <br />OWNER NAME L f3 •T&Q& <br />i. y [J :,.-j - ` I (� PHONE �, y 0/ - 7SS- - ` 3/}�y{/ <br />OWNER ADDRESS %iP 6 V Q & � a�� /C CITYISTATE/ZIPC"?_ kS `' � 7.2 in V <br />CONTRACTOR '-+�fLCG1.Lr`rc.� WQ�s i�29 IZZ•,� jQPHONEO269-3S —0625 <br />CONTRACTOR ADDRESS 166"'A t a2 ��a-`^� / ` CQ CITY/STATE/ZIP • 4T4JC+� 1 42^ <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE '�,C-57 C-61 D-09 Other NUMBER v% 713EXPIRATION DATE /—.7,c? — 26/9 <br />X <br />GEOGRAPHICAL INFORMATION: Coordinates v _71? -- 0'"176 Township n�S Range -39 <br />INTENDED USE ter a Irrigation/Agricultura IndUSlfl Water Quality Monitoring I..I SOII Sampling/Characterization <br />Public WaSystem ilw <br />Tt different from Owner Water YSTern Name L;ontact Name or Phone Number <br />TYPE OF WORK [Jew Well _ Replacement Well LI Well AlteratioNModification Other <br />Monitoring Well(s) # of wells L Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal C Cross -Connection Repair <br />New <br />Drilling Method XMud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth Excavation "' in diameter Open Bottom XGravel Pack/Gravel Size 8x/6 in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diamergr- p kA> Thickness/Gauge/ASTM Scheddl �� teel sll� Stainless Steel I Other <br />Grout Seal Depth 737 ro ft 1 Neat Cement (94 Ib gal water) 74anciCement l ri . _sack mix17 gal water <br />�(�antmito{3GP6 solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Y.,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 />MINIMUM 24 HOUR ADVANCE t4OTICE REQUIRED FO/R� (INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNEDJ�Ahdft� LI -2 4 TITLE/�/a _A.�Il�/� DATE <br />J <br />rn <br />D <br />M <br />F? <br />y�t-"^-DEPARTMENT USE ONLY <br />Application Accepted By ✓ � Date lel 6 ` L1, Area Employee 10# _4�v <br />Grout Inspection By &e ' Date k \ Zd SPECIAL Well Permit <br />Pump Inspection By Date - WAIVER Received <br />r� <br />Soil Boring Inspection By Date Constructed Well Depth J ft <br />COMMENTS F lv�. L S�� Loh - T5.(w. J LSO �1 _e cC aro. aft 1 <br />PE <br />SC <br />Received Check#/ <br />Amount <br />Permit/ <br />Codes <br />Info <br />B Cash <br />Remitted <br />Date Invoice# Well 10# <br />Service Re uest # <br />13i�_V <br />31A <br />ki <br />O- <br />,Nmagss� <br />EHD 43-06 WELL /PUMP PERMIT <br />4/3D/12 <br />l <br />