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/ 1 <br />WELL/PUMP PERMIT V <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LToN AVENUE • STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 1y�, iV / ` 111 �' t�. CITY/IJP Oil I(�;i -+ - <br />CROSS STREET t- • , L V Ga V. RIF APN '(20' PARCEL S12E LAND USE APDL/yI�CATION <br />DWNER NAME I S til Fe PHONE <br />DWNER ADDRESS-- nL ^-e— CRY/STATFJZIP L c-1,11 I CAq S:2-4 C <br />CONTRACTOR \� (N)kL 1 1 `i i 1, i 1 1 Cl PHONE r 3G9 <br />t - --2779 <br />-27 /7� I <br />CONTRACTOR ADDRESS l` x 4 CrTY/STATVZID 1 T A 7 J 1G 59 <br />SUBCONTRACTOR PHONE <br />ADDRESS <br />CITYISTAWIZIP <br />LICENSE \ C-57 '>.C-61 _ D-09 _ Other NuMBER ExPtrunoN DATE 1 t b <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE -: DomesticJPrivate 7 ImgaborUAgnculttual =: Induslnal - Water Quality Monitoring Sod Sampfing/Characterizatfon <br />Public Water System <br />udff. r+fromowner e+ nem FF <br />TYPE OF WORK New Well Replacement Well .- Well Alteration/Modtfication :: Other <br />Monitonng Well(s) S of wells Soil Boring(s) a °t D0"roe :. Geotechnr of Donical n�5 <br />Out -Of -Service Well - Out -Of -Service Well Renewal - Cross-Connecton Repair <br />New Pump Pump Replacement rump Hepalr _ NOW rvml �...N <br />WELL CONSTRUCTION <br />Drilling Method - Mud Rotary " Air Rotary - Auger Cable Tool Push Point I Other <br />Proposed Well Depth R Excavation in diameter _. Open Bottom - Gravel Padr/Grsveal Size In diameter <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thicxness/Gauge/ASTM Scheid Steel - Plastic Stainless Steel Other <br />Grout Seal Depth ft - Neat Cement (941b bag/&L0 gal water) Sand Cement sack mixR gal water <br />Bentonite (20% solids) _ Other <br />Grout Placement Method _ Pumped - Free Fall Other - Retardant / Accelerator (name) <br />Installed By - Driller Pump Contractor - Other <br />Concrete Pedestal - Dimensions: Width ft Length ft Thick in -. Christy Box Stove Pipe <br />PUMP "-< Sub memble 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 />MINIMUM 224 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-70697 l Q <br />SIGNED / •-". LC -I L��i�i W += - nTLE \ CIC ? �-CS XA'e Y) DATE <br />PA TMENT U E N Y <br />Application Accepted B Date <br />Grout Inspection By Dale 'T <br />Pump Inspection By _ Date -•p-- <br />Soil Boring Inspection By Date x <br />COMMENTS <br />Checko/ Amount I Dstr Permit/ <br />Cash Remitted Service Regt <br />EHO 17-M <br />u70r12 <br />AreaEmployee SDs <br />4PECIAL Well Permit <br />.; WAIVER Received <br />Constructed Well Depth <br />Invoice M <br />WELL RUMP PERMIT <br />N <br />D <br />0 <br />S <br />P <br />PA <br />EI Viet) <br />MAR 15 2018 <br />vv/RONM COL/N <br />E 1Y <br />-T N De., RTTAL <br />sl MENT <br />