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WELL/PUMP PERMIT <br />11, <br />SAN JOAQUIN COUNTY EwRoNYENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 952056232 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS fEXPIRES 1 YEAR FROM DATE ISSUED <br />' JoeADDREss �5 \ / I,LL RD Cr1Y/7IP 14,-41/ 97�- '^ <br />0 <br />CROSS STREET C OLQ401! 01! �A�PN oy 7/ y ' PARCEL Slg .L ,LAND USE APPUCAvom # <br />OWNER NAME 1 `vyCrNGJT/ 4 Ln')�1f��G 1 L� I:� PHONE <br />r:_(„KA I+ aa --4 <br />OWNER ADDREss NoF <br />, <br />J <br />%\- <br />_ <br />CONTRACTOR R 4Ze}2-Wol-cONS )"LIMA <br />36&L'(CE PHONE 0109 <br />�'L% <br />7y5 <br />JT- <br />p LN V4"s t - <br />CONTRACTOR AnORESS �Oo6� tied HOPE <br />"ft Cm/STATVZIP 6,fe.T C-4, <br />956 ;�.q <br />e� twE <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATCEIrLVP <br />LICENSE i I C-57 I I C-61 I I D-09 it Other Nurltaet 1 J ExPIRAnoN DATE <br />GEOGRAPHICAL INFoRMAnoN: Coordinates X Y Township Range Section <br />INTENDED USE 3CDomestidPnvate I i Irrigation/Agricultural i Industrial I I Water Quality Monitoring ! ! Soil Sampling/Chararlenzation <br />! Public Water System <br />It dtlremM from O—er wale, SyMm i CorItact ame x one i <br />TYPE OF WORK ! New Well i i Replacement Well i Well Aheration/Modification I I Other <br />1 Monitoring Well(s) S of wells i Soil Boring(s) II of I I Geotechnical r o1 borings <br />I Out -Of -Service Well I Out -Of -Service Well Renewal i I Cross -Connection Repair <br />New Pump I I Pump Replacement I I Pump Repair I ! Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ; i Mud Rotary I I Air Rotary ! i Auger I I Cable Tool I I Push Point I i Other <br />Proposed Well Depth 0 Excavation in diameter I i Open Bottom I I Gravel PackJGravel Size_ in diameter <br />I I Conductor Casing in diameter / Conductor Casing Depth _ft <br />Well Casing Diameter in Thidmess/Gauge/ASTM Sched I I Steel I i Plastic i I Stainless Steel I I Other <br />Grout Seal Depth ft I i Neat Cement (94 Ib bagl5-10 gal water) I i Sand Cement sack m1n/7 gal water <br />I Bentonite (20% solids) I I Other <br />Grout Placement Method I I Pumped I i Free Fall ii Other ii Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller I I Pump Contractor a Other <br />I I Concrete Pedestal Dimensions: Width ft Length ft Thick in I I Christy Box I I Stove Pipe <br />Al Submersible I i Turbine i I Other HP Pump Set_jQL ft Standing Water Level <br />1 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS �\ <br />SIGNED i� � TITLE DATE <br />DE RTMENT SE NNLLY <br />Application Accepted By Date' 3t Area Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By 1' JWMMXC Date — l �► WAIVER Received <br />Soil Boring Inspection By Date � V Constructed Well Depth It <br />COMMENTS_�.�5 r �IT:;— <br />,Ttl :7 -- <br />■ <br />.r <br />f a aa?'aa.,. V <br />.ECEVLED <br />JUL 2 S 2017 <br />,N JOAQUIN COUNTY <br />ENVIRONMENTAL <br />^I•.^.T` ENT <br />9 WED <br />NTAL HEALTiLt <br />'r-- - _ <br />E11D 43-06 <br />8104"WELL /PUMP PERMR <br />