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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUe-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT - CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADoREss li8I ,ie R.O►4V cn,,rza,STVC*TVN I S2C,b m <br /> �Q [ t� Q q a <br /> CRO"STREETG�ss /-or4'D APN 12"? O 1/'UQ ( PARCEL SQE3. IAYD Ua!APPLICATION tl I g <br /> OWNER NAME /'4GlPIC LEAS /�ri�D EG�c r1uL <br /> Anil SI4ISO(N gvta K _ / <br /> p /f1 /'�H/'Q m/STATE?JP Sro HO��_ �.7 � tIOZ 'S• <br /> Lj <br /> OwNEreAnoREss���QO/�� � mI�'1�`f—//e.d•T�vQf-(d�l_��6�1 / -- >LtAl "I <br /> CONTRACTOR Com? Or vYwi�`� X1 1 .._. 9/6 -`to?- �-T'35 <br /> WOO- <br /> p,^,�_c <br /> CONTRACTORAOOREa7 3ooO bVLVf� l Sj1�6-BT CRYISTATFJZIP WOO-Silk."rn6llro -TJPI <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADOREaa_ �� CITYISTATE/ZIP <br /> LI '736 <br /> pENiE (;-$1 C-61 D-09 DlherQ 7 NUMBER II o pE%PIRATN DATE <br /> .ypi <br /> GEOGRAPHICAL INFORMATION: Coordinates X 3 ,• 6 t-6 ` Y I Z'I-YS 2 111 0 Township?1" Range!{g Section Z;'INTENDED UsE Domesfic'Private Irrigation/Agricultural industrial Water Quality Monitoring /SDI Sampling/Characterization <br /> Public Water System <br /> I(d�aemrt from Ower N ra em e �a M um c <br /> TYPE OF WORK New Well Replacement Well Well AReralion/Modification Other <br /> Monitoring Wel!(s) 9 of wells Scil Borin s s d b""4' / <br /> 9( ) Geotechnical <br /> Cut-Of-Service Well Out-0f-Service Well Renewal Cross-Ccrmection Repair <br /> New Pump Pimp Replacement Pump Repair Raise Well Casing <br /> WELL CON1TRVCTION <br /> Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point Other <br /> Proposed Well Depth10 -ZO it Excavation 13 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / ConductorCasing Depth h <br /> Well Cuing Diameter in Thickness/GaugeiASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Sed Depth R /Neat Cement(94 lb bag15-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall I Other 7¢!Al T E Retardant/Accelerator(name) <br /> ,PEDESTAL Installed By Driller Pump Contracicr Other <br /> Concrete Pedestal Dimensions.Width ft Length h Thick in Christy Box Stove Pip• <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level h <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 /> MI HOUR ADVANCE NOTICE REQUIRED FOR INSFP'ECTIIONS-PLEASE CALL(209)95�3r-A7697 <br /> SWMED - TITLEP�J�T' 4�"6710ll DATE 13—3"4 "2-0/7 <br /> I <br /> I I <br /> JL 07, 2017 <br /> RECE��dE' <br /> 0NMENTAL HEALTH <br /> I 'Ut 3 rt ' 1 1 1 1 1 1 1 1 ° -RMIT/SERVICES <br /> SPs JOAQUTN CO .., <br /> EKVIRON►AE <br /> EP,A TMENT U E NLY <br /> Application Accepted By ate-7i I� Area Employee ID> <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Clete WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CM Amount Data <br /> Pertnitl <br /> Codes Info Remitted Smice R unt/ Invoice 0 Wall IDN <br /> � 3 C Z <br /> EHO 4346 W ELL.R1MP PERMIT <br /> hO 12 <br />