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ADDRESS <br />LICENSE , Ii C-57 )(, C-61 1 D-09 1 1 Other <br />CITY/STATEIZIP <br />NUMBER 9 798;J <br />PHONE <br />EXPIRATION DATE 1,2—.40 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDep USE I Domestic/Pdvale ,Ohgation/Agricultural I Industrial I Water Quality Monitoring I Soil Sampling/Characterization <br />rI Public Water System <br />If different from Owner: Water SVSIeM Name Cont -t NameCon— or Phone Number <br />TYPE OF WORK I New Well I I Replacement Well I Well Alteration/Modification I Other <br />I Monitoring Well(s) # of wells I Soil Boring(s) a of borings I Geotechnical 6 of borings <br />/II O'ut-Of-Service W 11 I Out -Of -Service Well Renewal I I Cross -Connection Repair <br />ew Pump 1ump Replacement I PUITID Repair i I Raise Well Casino <br />IDrilling Method i I Mud Rotary I I Air Rotary I I Auger I i Cable Tool 1: Push Point I I Other <br />'Proposed Well Depth ft Excavation in diameter t.J Open Bottom 1.1 Gravel Pack/Gravel Size in diameter <br />i Conductor Casing in diameter / Conductor Casing Depth _eft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad I Steel f-1 Plastic [I Stainless Steel I i Other <br />Grout Seal Depth ft t'I Neat Cement (94 /b bag/5-10 gal water) I1 Sand Cement sack mix/7 gal water <br />1 Bentonite (20% solids) I I Other <br />Grout Placement Method I I Pumped "I Free Fall Il Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller i I Pump Contractor I I Other <br />I Concrete Pedestal I JDimenslons: Width ft Length ft Thick in I Christy Box ; i Stove Pipe <br />PUMP 5' !Submersibles I Turbine I I Other HP Z. Pump Set 16 0 ft Standing Water Level 7 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 />MINIMUM 24 HOUR NCE NO IR B FOR INSPECTIONS - PLEASE CALL (209) 953-76997 <br />SIGNED _ TITLE DATE <br />fZMRpN� V COVN <br />J ZIArT.. T 1' <br />6 7 7 Employee 10# <br />SPECIAL Well Permit <br />WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 WELL /PUMP PERMIT <br />4130112 <br />WELL/PUMP <br />PERMIT . <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 9553.7697 FOR <br />INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />fr <br />JOB ADDRESS / O� 'YO <br />� <br />�'~ % / / l/ I' • t�L CITYIZIP Td� �Ya✓ gs <br />I INl) <br />CROSS STREET <br />APN <br />' ARCEL Sizj' LAND USE APPLICATION # <br />/1�"O/� <br />OWNER NAME J6V� ieJ stir, <br />., yO <br />PHONE ('4/11<J <br />OWNER ADDRESS 7.2 <br />CJ/T ~ <br />�� <br />CITY/STATE/ZIP �9�✓ ✓`✓�N /fW-?--Gd �• �� <br />/4L <br />CONTRACTOR 1',04 Q/w <br />J /Or4 Jit --�j(�/ <br />PHONE Wy <br />12YCONTRACTOR <br />ADDRESS -r SV <br />e <br />�s'<<i'YG1�/% fl' <br />r��7 <br />CITY/STATEIZIP g5a. ^��^� C /! 9U L <br />ADDRESS <br />LICENSE , Ii C-57 )(, C-61 1 D-09 1 1 Other <br />CITY/STATEIZIP <br />NUMBER 9 798;J <br />PHONE <br />EXPIRATION DATE 1,2—.40 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDep USE I Domestic/Pdvale ,Ohgation/Agricultural I Industrial I Water Quality Monitoring I Soil Sampling/Characterization <br />rI Public Water System <br />If different from Owner: Water SVSIeM Name Cont -t NameCon— or Phone Number <br />TYPE OF WORK I New Well I I Replacement Well I Well Alteration/Modification I Other <br />I Monitoring Well(s) # of wells I Soil Boring(s) a of borings I Geotechnical 6 of borings <br />/II O'ut-Of-Service W 11 I Out -Of -Service Well Renewal I I Cross -Connection Repair <br />ew Pump 1ump Replacement I PUITID Repair i I Raise Well Casino <br />IDrilling Method i I Mud Rotary I I Air Rotary I I Auger I i Cable Tool 1: Push Point I I Other <br />'Proposed Well Depth ft Excavation in diameter t.J Open Bottom 1.1 Gravel Pack/Gravel Size in diameter <br />i Conductor Casing in diameter / Conductor Casing Depth _eft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad I Steel f-1 Plastic [I Stainless Steel I i Other <br />Grout Seal Depth ft t'I Neat Cement (94 /b bag/5-10 gal water) I1 Sand Cement sack mix/7 gal water <br />1 Bentonite (20% solids) I I Other <br />Grout Placement Method I I Pumped "I Free Fall Il Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller i I Pump Contractor I I Other <br />I Concrete Pedestal I JDimenslons: Width ft Length ft Thick in I Christy Box ; i Stove Pipe <br />PUMP 5' !Submersibles I Turbine I I Other HP Z. Pump Set 16 0 ft Standing Water Level 7 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 />MINIMUM 24 HOUR NCE NO IR B FOR INSPECTIONS - PLEASE CALL (209) 953-76997 <br />SIGNED _ TITLE DATE <br />fZMRpN� V COVN <br />J ZIArT.. T 1' <br />6 7 7 Employee 10# <br />SPECIAL Well Permit <br />WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 WELL /PUMP PERMIT <br />4130112 <br />