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as- 16 0 WELLIPUMP PERMIT SAN JOAO!+IN COUNTY ENVIRONMENTAL HFAI_TH DEPARTMENT t 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED l;3,� m JOB ADDRESS (.Lr ►�` CITY/ZIP Ove, D O CROSS STREET I p1 eAPN-10 `J 10 I_b_ _ _PARCEL SIZE _LAND USE APPLICATION# p /� / N i� 2 OWNER NAME S-g4n(clI L/ �a-yf _ PHONE OWNER ADDRESS /Di • O,t' 23z _ CITY/STATE/ZiP C�O - l�r�'�+ % �•z� CONTRACTORN 7� I r) l'L7 v PHONE t/, 6i �!!6� CONTRACTOR ADDRESS f ` CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 'C-57 ❑ C-61 ❑ D-09 n Other NUMBER / 7-7— EXPIRATION DAT42,69/7 GEOGRAPHICAL INFORMATION: Coordinates X Y T nship Range Section---- INTENDED USE ❑ Domestic/Private `}irrigation/Agricultural Cl Industrial I I Water Quality Monit Ing u Soil Sampling/Characterization ❑ Public Water System If different from Owner: em----Water ystame ontact ame or Phone um er -- TYPE OF WORK XNew Well ❑ Replacement Well ❑ W I Alteration/ModificaV Other Monitoring Well(s) _ #of wells I.I it BOring(s) rings ❑ Geotechnical #of borings ❑ Out-Of-Service Well tut-Cf-Service Well ReCross Connection Repair ❑ New Pum 17 Pum Re lacement ❑ Repair Raise Well Casing WELL CONSTRUCTION Drilling MethodXMud Rotary ❑ Air Rotary U Au' r ❑ ble ool ❑ us Point ❑ Other Proposed Well Depth 3040 ft Excavation ' di meter 1 Open Bottom XGravel Pack/Gravel Size__ in diameter 17 Conductor Casing in diameter / Cond o C ing pth it , / Well Casing Diameter in Thickness/Gauge/ASTM Chad ❑ Steel Mastic a Stainless Steel Li Other__________ Grout Seal Depth it I 1 Neat Cement(9 bag/5 0 gal ater) a Sand Cement fa sack mixd7 gal water I_i Bentonite(20%solids) Other Grout Placement Method Pumped ❑ Free Fall a Other 11 Retardant/Accelerator(name) PEDESTAL Installed By Driller XP4p Contractor/ 11 Other F1 Concrete Ped stal ❑Dim sio s:Width it Length it Thick in ❑ Christy Box Stove Pipe PUMP ❑ Submersible n_ rbine I ther HP Pump Set it Standing Water Level _ft I HEREBY CERTIFY THAT I HAVE PREPAR THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OR NCES, TATE LAWS, D RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIV WI THE ALIFORNIA ONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LA S. MINIMUM 24 HOUR A CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)J953-`7697 ) SIGNED C TITLE- _ DATE a 0 0 v z a dre-1.11 I W 1 1 1 7717777171-771771!7rj__� I DEPARTMENT USE ONLY Application Accepted By Date Area Employee ID# D S Grout Inspection By Date Ll PECIAL Well Permit Pump Inspection By _ Date ❑ WAIVER Received Soil Boring Inspection By I Date . - Constructed WP 11 Det.>th71 COMMENTS_ Tr�l n.S �r C' 0 G� y 0 � s�j � S - Rcibe,-�s . PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# 30 62 i ol�(5 S b EHD 43-06 WELL/PUMP PERMIT 4/30/12