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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 />IVUIV-KEFUNUABLE rl=KMI I c GALL tZU`U) U04 -/b9/ FOR INSPECTIONS yt1`AYIKt J4l TEAR FROM UATE ISSUED <br />JOB ADDRESS 212 5. I.Owry. wS�R(�CwI��Ameo41D 9A • CITYIZIP 4Ai / `�` • 2 <br />CROSS STREET W • C ektW lay IIS k • APN {, 9%0400I I vr7DV �j EL SIZE 311. LAND USE APPLICATION # <br />OWNER NAME FC -S — -OMEr /S ( Qat V., (2 ane <br />Y") PHONE 915. 7(o9. 3515 <br />OWNER ADDRESS 1=0 TIZIIAI I 1 V, / PAKtW'1qjS1JI � /`OCRY/STATE/ZIP S t K�'JL'b . (CJA 95Z1q <br />CONTRACTOR Y � W iQJ�1�l''InL" ,,�I�yWL PHONE `09. ll 7700 <br />CONTRACTOR ADDRESS 1133 IIIPILT—ti / s DmIJE CITY/STATE/ZIP Gf4U ICA 95t0 3 L <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP (� <br />LICENSE AC -57 C-61 D-09 Other NUMBER -72pq0 `� EXPIRATION DATE • • 2-�O <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial - Water Quality Monitoring XSoil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Nam uoritad Nam or m um <br />TYPE OF WORK - New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of bonngs Aeotechnical r # of borings <br />Out-OfService Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger „Cable Tool Push Point Other <br />Proposed Welt Depth 191 D ft Excavation 40 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />'-t>&5 i Conductor Casing ___ in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth I& - 2 'Oft XNeat Cement (94 lb bagl5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped xFree Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller 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 P, <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 ADV NICE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED !`LJr N1�'� /' — TITLE SIR FF EA1(?1t IEFK DATE ;?M <br />Application Accepted By, <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection B y <br />COMMENTS 't --M <br />N <br />D <br />A <br />fn <br />EPARTMENT USE ONLY /_ ,0/1 <br />Date a' S –) i Area Lcd' Employee ID# �+' U n c] <br />kate� E, SPECIAL Well Permit / <br />Date I WAIVER Received <br />Date Constructed Well Depth ft <br />d ac ho.- Tr. <br />PE <br />Codes <br />Sc Received <br />Info B <br />heck <br />Amount Date Permit) Invoice # Well ID# <br />Remitted Service Request # <br />Will <br />150, <br />3470 <br />y 3 9 Z S I g <br />EHD 43-06 <br />4/3Dn 2 <br />WELL /PUMP PERMIT <br />2018 <br />wC <br />ou <br />INA 10), <br />