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Section Range Township GEOGRAPHICAL INFORMATION: Coordinates X <br />0`)0 14,1"1 013c6 WELL/PUMP PERMIT <br />co-0 - 0"*"‘ <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HAZELTON AVENUE STOCKTON CA 95205 - (209)468-3420 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />PHONE cl0 77 41 0 s-z- <br />44,3.'441 P NE -2 CO 7k <br />c4,14/ <br />CITY/STATE/ZIP WC/ q T31-1 <br />6A91 7 <br />Vet--K -cook kVA. o -A <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR AODRESSVO 610 i)Ci 15C)1 Kiev:1\15"-e". <br />NON-REFUNDABLE PERMIT 5 <br />QC, 10 et nsev,. \kci <br />?, t Irk." e*-- <br />"Za 10 k <br />CALL (209) 953-7697 FOR INSPECTIONS <br />ApN "Lock k I 0 <br />ciTyrzip <br />PARCEL SIZE 374- LAND USE APPLICATION # <br />Cnv/STATE/Zie SitjAny 111 e PiCYS/ <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATFJZIP <br />LICENSE NO-57 0-61 n D-09 Other NUMBER cljCi;P Cie) EXPIRATION DATEOCI-3'\ 1-4-°C-1 <br />TYPE OF WORK !: New Well )(Replacement Well 0 Well Alteration/Modification I-1 Other <br />C ot bottom !: ol bonngs Monitoring Well(s) X of wells 0 Soil Boring(s) Geotechnical <br />1,,..x)Dro-404, LI Out-Of-Service Well Ii Out-Of-Service Well Renewal tJ Cross-Connection Repair <br /> <br />Pump Replacement 0 Pump Repair ii Raise Well Casing <br />Proposed Well Depth 4)9 0 ft Excavation I u4 in diameter Open Bottom !" Gravel Pack/Gravel Size <br /> <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br /> <br />Well Casing Diameter 12_ in e7ss/Gauge/ASTM Sched 5baq U Steel palastic El Stainless Steel <br />Grout Seal Deplbli , Neat Cement (94 lb bag/5-10 gal water) K.Sand Cement - <br />0 Other <br />12 Retardant / Accelerator (name) <br />in ri Christy Box n Stove Pipe <br />PEDESTAL Installed By Driller 2 Pump Contractor W Other th.,-)O-C....r. <br />Concrete Pedestal :Dimensions: Width ft Length ft Thick <br />—jaBubmersibler Turbine F i Other HP ft Pump Set ft Standing Water Level <br />WELL CONSTRUCTION <br />Drilling Method .,:Mud Rotary Li Air Rotary Aug L Cobte Tool LI Push Point CI Other <br />sac!, mixf7 gal water <br />T V,/ 'A Bentonite (20% solids) ! Other 7,o.-oNves• ' <br />Grout Placement Method k9 Pumped Free Fall ," Other <br />in diameter <br />INTENDED USE Domestic/Private r. Irrigation/Agricultural Ii Industrial <br />t1 Public Water System <br />If different from Owner. <br />Water Quality Monitoring Li Soil Sampling/Characterization <br />Contact Name or Phone Number Water System Name <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 />MIMIVIUM 24. HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL j209) 953-7697 <br />su3INE`{ it c e 0— oC) ZDATE 6 5 /4 <br />DEPARTMENT US 0 Ii L Y <br />ApplIcatt-On Accept:id By <br />Grout Inspection By <br />Pump Inspection <br />Soil Boring Inspection "Sy <br />COMMENTS AAA) t•-•!:0c <br />PE <br />Codes <br />SC <br />Info <br />Redo ivLci <br />By <br />Checke/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request Invoice I <br />...440ke <br />q3-511, ‘ i- :777 (1 q Ok -./j- si2—t07s-qc,G, <br />,k 0, o :SS31:100V 311S Date /lit <br />Date t <br />Arer, Eiripioycc !Oft C * <br />L2 SPECIAL Well Permit <br />r- WAIVER Received <br />Date Constructed Well Depth <br />(:totAerrL ubac,F <br />6 <br />Date <br />ft <br />vq, <br />WE1.424)101/41Wa A EH043-06 ;1'0 -d- 4+1,4* r..9.014,4 <br />4/30I12