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T f� <br />1s880 -EAST WELL WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95206.6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 12242 N. ST RT 88 !;o <br />-CITY/ZIP r.nliT A 5 i d fl IcaossSTREeT LIVE OAK RD. AP063-18-025 <br />OWNER NAME PARCEL SIZE 1 5 7 . O�ja [40 USE APPLICATION # <br />J KI � �-25 <br />r - NHONE 209 931 -4730 0 <br />OWNER ADDRESS 1 i O Z���MSTOCK RD . ST /PO Box 7�8 a 3(vSI'OCKTON 95215 <br />ITY/IP <br />CONTRACTOR , Delta Ptimv 4'TnCKTn T ARMATIIRF r *^^n'^R jn7nRKS <br />CONTRACTORADDREss 646 S. California Street <br />CITY/STATE/Zip- <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 X C-61 O D-09 0 Other <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />NUMBER <br />CtTYISTATEJZ\P <br />Stockton, CA 95 <br />PHONE <br />EXPIRATION DATE 08/11 <br />Y Township Range Section <br />INTENDED USE ❑ DOmestic/Private CXfkgation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characteriza(ion <br />0 Public Water System <br />If different from Owner: a er ys em ame <br />n a ame or one um er <br />TYPE OF WORK ❑ New Weil 0 Replacement Weli C Well Alteration/Modification 0 Other <br />❑ Monitoring Wells) # of wells 0 Soil Boring(s). # or borings # of borings <br />Out -Of -Service Well , G Geotechnical <br />L Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />e New Pum um Re lacement 0 Pum Repair WELL CONSTRUCTION 0 Raise Well Casing <br />Drilling Method C Mud Rotary Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth P it Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ft <br />Grout Seal Depth ❑Steel 0 Plastic ❑Stainless Steel ❑Other <br />P ft C Neat Cement (94 lb bag/5-10 gal wafer) Sand Cement <br />Bentonite (20% solids) ]Other sack mixl7 gal water <br />nt <br />Grout Placement Method ❑ Pumped 1, Free Fall . Other <br />❑ Retardant /Accelerator (name) <br />PEDesrAL Installed By 0 Driller 3 Pump Contractor 0 Other <br />Concrete Pedestal Dimensions: Width ft Length 9 ftThickin ❑Christy Box BOXD Pipe <br />.PUMP 0 Submersible❑"bine 0 Other <br />HP Pump Set It 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. 1 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 COMPENSAT <br />A tA <br />Application Accepted Sy <br />Grout Inspection By <br />Pump Inspection By <br />EHD 43.06 <br />8/04/08 <br />HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CEO <br />DEPARTMENT USE ONLY <br />Date 101/1.1 <br />Date <br />Date 0 o I rl <br />DATE __Q/3/17 <br />Area � I_C71 Gl Employee 1D# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />WELL /PUMP PERMIT <br />m <br />n <br />m_ <br />G <br />NMI, <br />MM <br />