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Section Range Township GEOGRAPHICAL INFORMATION: Coordinates X in 7 Christy Box 7 Stove Pipe PEDESTAL Installed By U Driller C Pump Contractor N, Other -VV.-- -•1/.. - Concrete Pedestal .- Dimensions: Width It Length ft Thick TYPE OF WORK 0 New Well y9Replacement Well Cot borings-ol borings 0 Monitoring Well(s) It of wells C. Soil Boring(s)Geotechnical 0 Out-Of-Service Well LI Out-Of-Service Well Renewal U Cross-Connection Repair Or1ew Pump Pump Replacement Pump Repair Ii Raise Well Casing WELL CONSTRUCfIQN Drilling Method ?flitud Ropry 0 Air Rotary C Auger Ii Cable Tool CI Push Point n Other Proposed Well Depth t'f° ft Excavation / In diameter Open Bottom r, Gravel Pack/Gravel Size in diameter Conductof Casing in diameter / Conductor Casing Depth ft Well Casing Diameter (,0 in Thickness/Gauge/ASTM Sched .j Steel )16 Plastic 0 Stainless Steel Cl Other Grout Seal Depth .2-6 g.)' ft 7 Neat Cement (94 lb bag/5-10 gal water) y;ISand Cement sack mixI7 gal water I Bentonite (20% solids) Other E Well Alteration/Modification rl Other Grout Placement Method rPumped : Free Fall Other II Retardant Accelerator (name) Jr(rrEumo Usk Xpomestic/Private E Irrigation/Agricultural El Industrial Water Quality Monitoring Li Soil Sampling/Characterization ( Public Water System Waier System Name It different born Owner. ContactName or Phone Number 3--/ Employee ID* 2/48 C SPECIAL Well Permit C WAIVER Received ' Area DEPARTMENT USE ONLY Application Accepted By Grout inspection By Pump inspection By —Pate Date Date Crrvale L. PHONE cl 77 1 c)2-Y CONTRACTOR EXPIRATION DATE .v. •,, WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East' HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED c 4 JOB ADDRESS CROSS STREET Sc•AN) kV-C. APN "2-c)"1 1 1 C)1 C) PARCEL SIZE I 4.5;tLAND USE APPLICATION # OWNER NAME OWNER ADDRESS P (- (310 I. \ç&-ç_-'----vIZA J Vcidi 4-c,—* . CONTRACTOR ADDRESS Vt. 6.ql.(,,.., ciTy/sTATEizip V...,,, tutr....c., C.4- 1(f-1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 72C-57 ' I C-611 D-09 [1 Other NUMBER 1 crryisTATE/zip Tic-4.1. (3 C3 7 7 PHONE )0 Submersible( , Turbine ; Other HP Pump Set ft Standing Water Level ft 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. ,11:4111islUM,24 Hr ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE 6 f-L-r- DATE 1.-2-/-/ ..,• .: - • sii. -----,-„ _ - --4. - ,,-•1* 3 ...--, - , i 1.--...niasim.......,.....ar. 7 .J.,..„ • ;1)0:: _ ' ' ),137-T. ....... ..' '' . lir r-11 slir .. . r, . I , „I • .! I' - .• . I .: ' ___ tJ ; IV t . PAYMENT RECEIVE(.) c - AJG 3 0 !,11 6 :Ar JGA01.1 N COf .7:NVin0mi.:N rAl ,.........- 1 y COMMENTS -114,t) lutt" (5E20 730 Cd/lt-pSei" 4,4 GNU 4€ Soil Boring Inspection By pate CrstruFted Well Depth t / WY PE Codes SC Info Received By Cf,....4 jr tic fi'' ash Amount Remitted Date Perm W Service Request It Invoice e Well IDe /137o //) Go 4 r I Li. .14, 3&I — q.50/1 i, C-'D a- -06 7 5 (et 0 A 0 0 WELL /PUMP PERMIT EHD 4106 4/30/12