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-7 �r- - g9"5& y PIZ - <br />WELUPUMP PERMIT <br />SAN JOAQUIN ItOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS <br />STOCKTON CA 95205 - 12091468-3420 <br />ADDRESS ✓ ".1ff if*SIC Gr Qco Atom- <br />om-�% ��j �'+'•T � CRV/ZIP^•'•iAM` (7�/ !/ <br />SS STREET 1 • ' ,^ Avir. APN �f/ ! I✓V - PARCEL SIZE /� LAND USE APPLICATION # <br />IER NAME oy�TS)i rA•!f�y�b'a,'f- COMM SIFF�✓�;'$ cT PHONE y, /fes <br />IER ADDRESS2#39 v �. �"-^ ^J� , VA ,Si�-� � t/o0 CITYISTATE/ZIP&y7�77Pj lkosr`M M <br />TRACTOR PHONE <br />CONTRACTOR ADDRESS_ CITY/STATE/ZIP_ �/�Q-04 LJ <br />MFOCONTRACTOR 7 �✓�'<• PHONEA / / ^ rr"DD <br />ftWONTRACTOR ADDRESS Rl✓IE CITY/STATE/iLT C14 95-617 <br />LICENSE NC -57 C-61 D-09 Other NUMBER7�o90 y EXPIRATION DATE - <br />DOMESTIC WELL SAMPLING: General Mineral/61iform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE DomestWPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) a of borings V Geotechnical tt orbormgs <br />7 Out -Of -Service Well Out -Of -Service Well Renewal :7 Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary '�r Air Rotary )4uger Cable Tool C1 Push Point Other <br />Prrop,.osed`' 0 Depth 1,45 4W ft Excavation 16 I/ in diameter D Open Bottom Gravel Pack/Gravel Size in diameter <br />lm 10 <br />Conductor Casing in diameter / Conductor Casing Depth _ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched _ Steel i Plastic Stainless Steel D Other <br />Grout Seal DepthLl — 70 fit XNeat Cement (94 Ib bagl5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped i-1 Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By :I Driller ( Pump Contractor Other <br />Concrete Pedestal Dlmensions: Width ft Length ft Thick in . Christy Box Stove Pipe <br />PUMP Submersible_ Turbine Other HP Pump Set _ ft Standing Water Level It <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 />MINIMt/7'M 24 H U / CE NOTICE REQUIRED FOUR JI <br />SIGNED ✓ •�r,3c� TITLE 5V <br />PA TMENT SE NLY <br />/J��1 ) �� <br />Application Accepted By mil ! 1 Date <br />Grout Inspection By _ 1 Data <br />Pump Inspection By Date <br />Soil Boning Inspection By Date <br />COMMENTS /7 �// fit 1 �17 <br />(iii f� 5( <br />PE SC Received C, Check#/ Amount Date Pertnitl Invoice # Well ID# <br />Codes Info s Remitted Service Reguest # <br />SL3�J-13 11 ►"� t�1 p - <br />S -`PLEASE CALL (209) 953-7697 <br />IKF.rfA DATE // i-/7 <br />Area Employee ID# 2 1 c TC" <br />PECIAL Well Permit <br />WAIVER Received <br />Well Depth <br />14306 8/01/16 <br />WELL/PUMP PERMIT <br />h <br />VED <br />0 20v <br />H�ALiI-; <br />i�i <br />14X r�� <br />