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To: San Joaquin Co EHD Page 2 of 4 2016-11-09 23:23:35(GMT) ' From: Dona Mann -A haA S caul( WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzrL 70h AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT__ CALL(209)953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos Ann.tE.3.5 -.-l.... �..-1..+1 d's''�/I:��1iF\ ..C: CITY�/_IP i�4/ ..I- �^-�t ypr�p{ i pp CROSS STREET \t i(� �•/t C C[ ��/-': APN �J'�+ r Y�-'�W PARCEL SI:M— LAND USE{APPLICATION#_ -„_,_,,,-,-�; _ OWNER NAME Y\_�•, (+t,..}.+T t C PHONE i l OWNER ADDRESS 7 j•J)Cf''�'. "(t�}Y(� _ CSI"TY/STATULP 3�vf'y ✓ 1t'� � � (n CONTRACTOR l4J�' %L� V• f 1 l�Z r (�. ' �y-{� PHONE/y`f�r 1" {,� i, .� �L.�....._.. CONTRACTOR ADDRESS �,�� I�l t'.�I 4'.11'7rL�F'I-Q. e CITYiSTATEJZIP? . II 1C.i SUBCONTRACTOR : � >E�()-1 1 1 rrA (�1r1('F j_-�2S�n�iR ______-_�_�pPHONI LL 313 W 2'0 $V9CONTRACTOR ADDRESS x4. "5:1 jAty/ .'. J,IC._Ufit O! _-- CITY/STAT621P -}�i Y'�}'�(�(1 A ��' G 7 F UcENsE C-57 D C-61 C 7 D-00 Other NUMBER i - ExMRATION DATE 1 I L1 GEOGRAPHICAL INFORMATION: Coordinates X ��•'y -t �, Y,�- �. Township_ Range Section INTENDED USE _ Domestic/Pdvate C Ird9ation/Agricultural _Industrial T'WalerOuahty''Oonitoring YSollSampling/Characterization ) Public Water System 1 If differed rmm Owner, vmlw yan ame C,,ntdnro nr a ur.,eer TYPE OF WORK L"New Well i- Replacement Well U Well Allerallon/M1odification L Other L Monitoring Well(s)__#of vrelis U Sol Borings) eprEO J )(Geolechrxell. L Out-Of-Service Well U Oul-Of-Service Well Rerernl I Cross-Connection Repair — ! C New Pump _Pump Replacement LO Pump Repair L Raise Well Casing fi WrLLCoNsTRucnoN + Drilling Method r Mud Rotary, C Air Rotary Auger I Cable Tool C. Push Point Other�Q.( v1iAj_ Proposed Well Depth� ti Excavation $_In diameter t-Open,Rolll- t Gravel Pack/Gravel Size er L Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diamater_In T1iicknes9JGau9a/ASTM Sched C Steel E Plastic c Sla;nlesSSleel C Other_ Grout Seal Depth it Neat Cement(941b bag,'-10 gal Water) L Send Cement ---sac*rrAz/7 gat welel L Dentonte(20%soCds; L'Other Grout Placement Method 7 Pumped bwtee Fail -Other C Retardant i Accelerator(name) ftqgATAL Installed By L Driller L Pump Contractor L Other C Concrete Pedestal C Dimensions:Width_R Length It Thick In C Christy Box 7 Stove Pipe PUMP L SUGmerslbIBL Turbine C Otlier HP Pump Sel h Standing Water Level tt i I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN i 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. nIIVILIM 24 OUR AQVANCSNOTICE REQUIRED F R IINSPECTIONS-PLEASE CALL(209 953-7697 SIGNED1.11.+1. jt-,. •+✓\ / r i%L%At:�� TITLE V '; I•' �� DATE 1 )I✓i i - - IE 9 201 Ij I � ( i - - I I EPARTMENT USE ONLY Applicaton Accepted B Dale �_C 1� Are t` Employee Irl#is k� Grout Inspection By Date SPECIAL Well Permit Pump I—Traction By, sato / D WAIVER Received Soil Boring Insperlt. n�By Dale _A/ Constructed Weil Dept ft COMM T' pe�=f-c• J•'nLe.�• -FE SC 1 Received ' Check#1 Amount Permits Codas IDfD BY Cash Remitted Date service Re uest# invoice# _ - Well ID* - — - 1. 11h Ip S IZn07W2,01-- — '—— i WCC Pu1.W V"U'r 4�ar12 Received Time Nov. 9. 2016 3: 20PM No- 0329