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l�- <br /> W7 - .�F 3v 11� ✓ <br /> WELL/PUMP PERMIT <br /> SAN JOAOMN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA LTOH AVENUE-STOCKTON CA 95205-(209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> n /y 1 O ^ m <br /> JOB ADDRESS 2 21 1 � 1 T f� W pf n� p d GRY gZP�Qf1"Gct/rlrlh <br /> CROSS STREET f*w R APN 0 (3-I I -00-5 PARCSLSRE_( I—LAND USE APPLICATION# m <br /> DINNER NAME PHONE /�a{{ �J/L'(// <br /> OMER ADDRESS � CITY/STATEZP�/ �6 J V/ D <br /> CONTRACTOR C�Inn�OY' 11 CTII 1 � err 1PHONnE �4- 3/G7- 3101 <br /> CONTRACTOR ADDRESS '1 V 2 T.dgiiY"GI �w-/ CITY/STAIE(LP IBX I a J/z <br /> SUBCONTRACTOR N^�' L� PHONE A-1 <br /> SUBCONTRACTOR ADDRESS MCRYISTATEZP N/A <br /> LICENSE )657 C-61 D-09 Other NUMBER 66400 y- EMRATIOMDATE 5/31/2014 <br /> GEOGRAPHICAL INFORMATION: COOrdlnateSX Y Township_ Renga_ Section_ <br /> INTENDED USE DomesticlPdvate IMgatiONAgricultural Industrial Water Quality Monitoring XSoff Samping/Charecteriration <br /> Public Water System <br /> HalHerontnml Owmr: ev ys em ame n < eme er rH um <br /> TYPE Or WON K New Well Replacemanlwell Well Alteration/Modification Other <br /> Monitoring Wells) #ofwellS Soil Bunng(s) eelnonrw T(Geotechnical 2a1bonln, <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary (Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10'13, It Excavation In diameter Open Bottom Grovel Pack/Gavel Size In diameter <br /> Conductor Casing In diameter / Conductor Casing Depth R <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth it Neat Cement(94 lb bagl5-10 gal water) Sand Cement sack m&17 gal wafer <br /> Bentonhe(20%solids) ?((liher sal 6"-klL'� ( IAnder If <br /> S( ) <br /> Grout Placement Method Pumped Free Fall Omer Retardant/Accelerator(name) <br /> PEDESu Installed By Driller 'Pump Contractor Omer <br /> Conereb Pedestal Dlmenalens:WMlh ft Length ItThick In Christy Box Stove Pipe <br /> PuaP Submersible Turbine Other HP Pump Set ft 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 COUNT'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 /> MIN IMU24 DOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7897 <br /> SIGNED TITLE rmneer DATE GSI J/I <br /> r <br /> E C U <br /> L <br /> T <br /> QE ARTMENT U /E NLY <br /> Appliwtlon Accepted By Dale (J Area Employee IDN L <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Data WAIVER Received <br /> Soil Boring Ins action Date Constructed Well Depth-R <br /> COMMENTS <br /> LI/ 7 <br /> PE Sc Reulvad he AmountDare ParmlU InvoiuR Well lop <br /> Codes Info B ash Remitted Service Re uest# <br /> y sD S Cb777 <br /> EHDN}IIS VIRL RUMP PERMIT <br />