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WELL/PUMP PERMIT i L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 NON-REFUNDABLE �PERMIT `� M CALL 209 p9513-7697 FOR INSPECTIONS EXPIRES 1 YEAR`FROM DATE ISSUED JOB ADDRESS ,/-LOa / �• 1'IAr1rhGy /\y, Cm/Zlp Lc m4 TI/Gt♦O� g7330 m K10 (� 1 q/A q s CROSSSTREET KID R1A. 1� APN I1/'2J-OD7 PARCELSQ//E lal-AND USEpAPRJOATmN N / o OWNER NAME Pr�e//Ypon YIQL�QbroCC L) 1ny ' Ia //Cf/ i,L2/�L )l1 P! // PHONE 1-/y�-2/7p- /��(J Y OWNER ADDRESS IZL2(77 �. I-I AAT/CY Ftl.�/ �� t./HCI TY1STATEZP'+Yr>�1/�/ /—rV-?9V ,1 I t CONTRACTOR Ned 0. 4-1,i-507 -' J 4'5soG)Aft5 PHONE 2001 - 367- 370/ CONTRACTOR ADDRESS 6102 LnJN.5�Yi4l L✓AY CITY/STATEZP LItli/CAI -ISZgo SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STAA{�TAOEMP LICENSE C-57 ❑C$t 01}09 ❑Other NUMBER vU EXPIRATION DATE DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibramochloropropane(439 )❑An enic(4393) INTENDED USE ❑DomestldPnVBte ❑Inigatlon/Agncuhural ❑Industdal ❑Water Qualify Monitodng dl Sampling/Characterization ❑Public Water System I(dllre.rd(rom Owren: WaterSylumemew re um TYPE OF WORK El New Well ❑Replacement Well ❑Well ARerationlModi#cetion []Other ❑Monitoring Wells) #ofwells ❑Solt Borings) aalanms aatechnicel_,�'ixx res ❑Out-Of-Service Well ❑Out-OfServke Well Renewal ❑Cross-Connection Repair New Pump Q Pump Replacement 171 Pump Repair Raise Well Casing PAAY WELL CONSTRUCTION Drilling Met (�klud Rotary ❑Air Rotary [R/Auger ❑Cable Tool ❑Push Point ❑ Other CCr-C Proposed Well Depth $D R Excavation 4-3,n in diameter ❑Open BoRom ❑Gravel Pack/Gravel Size G D tingl�eeter ❑Conductor Casing in diameter / Conductor Casing Depth R SAN JOAQUINLrl' WBII Casing Diameter in Thkkness/OaugelASTM Sched ❑SHSI 0Pias9c ❑Stainless Steel CoC Grout Seal Depth R Neal Cement(94166ag/510 gal wale!) ❑Sand Cement HDU-TN�LC N�ter ❑Benlonite(20%solids) El Other Tr-ew.� Grout Placement Methotl$iPumped ❑Free Fell ROther JI ❑Retardant/Accelerator(name) P110Installed By ❑Dnller ❑Pump Contractor ❑ Other ❑Concrete Pedestal@imenslorm:Width_ft Length RThick in ❑Christy BOX ❑Stove Pipe PUMP ❑Submersible❑Turbine ❑Other HP Pump Set R Standing Water Level fl I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI M 24 H IJ �f0'CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED IC �- '�/ / TITLE -z e M DATE • �•�, DEPARTMENT USE ONLY I Application Accepted By Data /-/ Ares3/Gl °I EmployeelDR Afi/✓)GR Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Dale ❑ WAIVER Received Soil Boring Inspection By Dale a Constructed Well Depth K COMMENTS 5 �� PE Sc Received Chat; Amount PermiU Invoice III WBII ID# Codes Info B ash RemNted Date ServiceRa nest# Ire ,>•, F cT ,