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4 <br />e / $ <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1860 EAST HAZELTON AVENUE: - STOCKTO14 CA 95205 - (209) 466-3420 <br />NON-REFUNDABLE <br />� PERMIT �. CALL (209) 953-76977 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS { 1 1� ' f ►.� {L -a-4 Q (w--1�V �Q CITYIzIP —_L/%�g�d P !� <br />CROSS STREET `• ��Q-•� V IS�_ APN /r/]•t � " J& -N •`I09 P <br />�A <br />/R <br />JCEL SIZE � LAND USE APPLICATION # <br />OWNER NAME �.! • [� II"( PLC••i 0.O FAt!b -• l L,Y:" rI _ _ _ PHONE <br />7 { R L <br />OWNER ADDRESS ^F C) .� / �-•� �• CITY/STATEILP r✓O t J�•�.. TAD 8 <br />CONTRACTOR IV", I -C P� /�eT��� /� G ��� PHONE SGfj CAN, <br />�� ALL �Q - <br />CONTRACTOR ADDRESS i ZO t C, • hLJ-Q VJA k_ 51a I0 CITYISTATE(LP T `I•� J 1 ALO <br />T i r z <br />SUBCONTRACTOR i/ PHONE 41 14 - Z7�' <br />SUBCONTRACTOR ADDRESS O �� CITYISTATE2IP �- A.MR Gr�C <br />I <br />LICENSE C-57 C-61 D-09 _ Other NUMBER'701 EXPIRATION DATE 02.28.2018 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />HTENDED USE -: Domestic/Private - Irrigation/Agricultural "- Industrial - Water Quality Monitoring it Sampling/Characterization <br />O Public Water System <br />If dfferert frcm Owner. Vrator System Name Cor6aa Name or PF Number <br />TYPE OF WORK ❑ New Well - Replacement Well :. Well AiteratioNModification - Other <br />D Monitoring Well(s) # of wells Soil Boring(s) a °f bodngs XGoolochnical �_e of borirya <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Fume Pumo Reolacement "' PUmD ReDair Raise Well Casino <br />WELL CONSTRUCTIO <br />Drilling Method Mud otq -. Air Rotary _ Auger _ Cable Tool _ Push Pont "" Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Sizo in diameter <br />.- Conductor Casing In diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in ThicknesslGauge/ASTM Schad : Steel Plastic - Stainless Steel - Other <br />Grout Seal Depth ft 4 Neal Cement (94 lb bag/S-10 gal water) Sand Cement sock mix/7 gal ureter <br />Bentonite (20% solids) _ Other <br />Grout Placement Method : Pumped T Free Fall V Other Retardant / Accelerator (name) <br />PEDESTAL Installed By : Ddller _ Pump Contractor - Other <br />._ Concrete Pedestal _ Dimensions: Width It Length It Thick in T Christy Box 71 Slave 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 />MIUMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE VP / Exploration CoordinatorDATE 01.09.2015 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring In55 cUon By <br />.Nv1ENTS <br />ER TMENT S N <br />Datc <br />Date <br />Date <br />�il—j Date <br />4 y4`j <br />,� ' 40' <br />Fn�O, �0�8 <br />�TyopCN� <br />MFNT . <br />Area ff Employee ID#.� <br />SPECIAL ell Permit <br />WAIVER Received <br />PE SC Received Check#! Amount PormlV Invoice # Wall ID# <br />Codes Info B Data Cash Remitted S rviee Ra uast # <br />EHO4306 E01/16 <br />(>, . -?t &S� f3 J& <br />WELL i,TUMP PERMIT <br />