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' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> A hQQ' /I //�1� y <br /> JOB ADDRESS Z 7-v ly Soi T M J4o r-r�, X�0 flrJ Ro A17 CITY21P /"� ' ow, 9 <br /> Q Q) Ct't Z. 0 <br /> CROSS STREET RIOOoJ f�`r•F,' ��J L APN Zb I ZI C Q O PARCEL SIZE A[.�!S LAND USE <br /> APPLICATION# Q' m <br /> OWNER NAME PE r£,'r &rA pErpT;F-% TPHONE 7 LAS/��(♦Y�Q 5:51-0 •"' <br /> OWNER ADDRESS Zy 7g C-.4s-r4,i{�'.^• ! y, CITY/STATE/ZIP Q/ ) L 1�p CIA 1✓✓O Q <br /> CONTRACTOR Ajyjj �tLED (i',—"E 0 G.�DVI�AOII��`^ rA (PHONE Z�l — 4b 7'j� <br /> CONTRACTOR ADDRESS O 3c-7 .7 Tl�W /7 O A)' CITY/STATE/ZIP 3TC GK-ra.-j 'j CO.- g14sz?r <br /> SUBCONTRACTOR .411 W£�1 A bA dj00^M E�t PHONE 1 I It —/(D 7 - 3-f5- <br /> SUBCONTRACTOR <br /> -fJ <br /> SUBCONTRACTOR ADDRESS 331•9 Fi 4-!w%ErALA7 ,Q�„ CITYQ/STATIE/ZIP ISAAQkQ C-r0'A.A.I CA S'71 <br /> LICENSE A0-57 C-61 D-09 Other NUMBER O 0[.Z EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private - Irrigation/Agricultural Industrial _ Water Quality MonitoringSoil Sampling/Characterization <br /> Public Water System Ti M CV£l I A r (;oft)Uto7^10 0( <br /> If different from Owner: Water ys efn Name on a Name or Phone N=Der <br /> I YPE OF WORK _ New Well Replacement Well Well Alteration/Modification - Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #ofbonngs •,�Geolechnical �_ #orbodngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Conn tion Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched - Steel Plastic - Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) - Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other 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. 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 24PHOUR <br /> �ADVANCE NOTICE REQUIRED FO INSPECTIONS-PLEASE CALL(209)953-7697 p <br /> SIGNED �t/YY1 t.•Ca9./�.7Ti/�. TITLE �RO�ECt M,4 J.4 r,9r DATE -7-I b- IO <br /> ZE PA <br /> � YM�NT <br /> CE ® <br /> 182018 <br /> S All AQUI <br /> IRO/yMF OU/y7, <br /> AL <br /> �FPgR MENTI <br /> I H1 —9 <br /> PA TMENT U E/ ��C\y� <br /> 0 <br /> Application Accepted By ate ` Areaieiqq Employee ID :w <br /> Grout Inspection By Date LtPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date 9� /� Constructed Well Depth ft <br /> COMMENTS 1 <br /> PE SC Received Amount Date Permit' Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> -a 5'<5-1 o fig- t,�Po6 <br /> EHD 43-06 G i )►{, WELL/PUMP PERMIT <br /> 4/30/12 w <br /> ✓i sa-= Z6.o0 <br />