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Section Range Township GEOGRAPHICAL INFORMATION: Coordinates X <br />in 7 Christy Box 7 Stove Pipe <br />PEDESTAL Installed By U Driller C Pump Contractor N, Other -VV.-- -•1/.. <br />- Concrete Pedestal .- Dimensions: Width It Length ft Thick <br />TYPE OF WORK 0 New Well y9Replacement Well <br />Cot borings-ol borings 0 Monitoring Well(s) It of wells C. Soil Boring(s)Geotechnical <br />0 Out-Of-Service Well LI Out-Of-Service Well Renewal U Cross-Connection Repair <br />Or1ew Pump Pump Replacement Pump Repair Ii Raise Well Casing <br />WELL CONSTRUCfIQN <br />Drilling Method ?flitud Ropry 0 Air Rotary C Auger Ii Cable Tool CI Push Point n Other <br />Proposed Well Depth t'f° ft Excavation / In diameter Open Bottom r, Gravel Pack/Gravel Size in diameter <br /> <br />Conductof Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter (,0 in Thickness/Gauge/ASTM Sched .j Steel )16 Plastic 0 Stainless Steel <br /> <br />Cl Other <br />Grout Seal Depth .2-6 g.)' ft 7 Neat Cement (94 lb bag/5-10 gal water) y;ISand Cement sack mixI7 gal water <br />I Bentonite (20% solids) Other <br />E Well Alteration/Modification rl Other <br />Grout Placement Method rPumped : Free Fall Other II Retardant Accelerator (name) <br />Jr(rrEumo Usk Xpomestic/Private E Irrigation/Agricultural El Industrial Water Quality Monitoring Li Soil Sampling/Characterization <br />( Public Water System <br />Waier System Name It different born Owner. ContactName or Phone Number <br />3--/ Employee ID* 2/48 <br />C SPECIAL Well Permit <br />C WAIVER Received <br />' <br />Area <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout inspection By <br />Pump inspection By <br />—Pate <br />Date <br />Date <br />Crrvale L. <br />PHONE cl 77 1 c)2-Y <br />CONTRACTOR <br />EXPIRATION DATE <br />.v. •,, <br />WELL/PUMP PERMIT <br />SAN JOAOUIN 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 />c 4 JOB ADDRESS <br />CROSS STREET Sc•AN) kV-C. APN "2-c)"1 1 1 C)1 C) PARCEL SIZE I 4.5;tLAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS P (- (310 I. \ç&-ç_-'----vIZA J <br />Vcidi 4-c,—* . <br />CONTRACTOR ADDRESS Vt. 6.ql.(,,.., ciTy/sTATEizip V...,,, tutr....c., C.4- 1(f-1 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 72C-57 ' I C-611 D-09 [1 Other NUMBER 1 <br />crryisTATE/zip Tic-4.1. (3 C3 7 7 <br />PHONE <br />)0 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 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 />,11:4111islUM,24 Hr ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE 6 f-L-r- DATE 1.-2-/-/ <br />..,• <br />.: - • <br />sii. <br />-----,-„ <br />_ <br />- --4. <br />- <br />,,-•1* <br />3 <br />...--, <br />- , <br />i 1.--...niasim.......,.....ar. <br />7 <br />.J.,..„ <br />• <br />;1)0:: <br />_ <br />' ' <br />),137-T. ....... <br />..' '' <br />. <br />lir <br />r-11 <br />slir <br />.. . r, . I , „I <br />• <br />.! <br />I' <br />- .• . I <br />.: ' <br />___ <br />tJ <br />; <br />IV <br />t . <br />PAYMENT <br />RECEIVE(.) <br />c - AJG 3 0 !,11 6 <br />:Ar JGA01.1 N COf .7:NVin0mi.:N rAl ,.........- <br />1 y <br />COMMENTS -114,t) lutt" (5E20 730 Cd/lt-pSei" 4,4 GNU 4€ <br />Soil Boring Inspection By pate CrstruFted Well Depth <br />t / WY <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Cf,....4 jr tic fi'' <br />ash <br />Amount <br />Remitted Date Perm W <br />Service Request It Invoice e Well IDe <br />/137o //) Go 4 r I Li. .14, 3&I — q.50/1 i, C-'D a- -06 7 5 (et 0 <br />A <br />0 0 <br />WELL /PUMP PERMIT EHD 4106 <br />4/30/12