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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENNRONMENTAL 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 ADDRESS 3263 I:.Cherokee Road CITYIZIP Stockton 95205 <br /> `4cresl -- o <br /> CRO33 STREET Ne won Road APN 132-070-100-000 PARCEL SIZE 139 80(1 LAND USE APPLICATION X a <br /> OWNER NAME (landau P Eital Raj kovich-Contact:Jerry Grunzinger,KPDelle lopmen r�„� 314.960.0849 <br /> OWNER ADDRESS 8025 Forscth Boulevard CIT[/STATE/ZIP SNE <br /> 'PVI. I-01115,MO 63105 <br /> CONTRACTOR Nest Coast Exploration-Andre%% I Iemandez.(Avner/Operator PHONE 209.985.7541 <br /> CONTRACTOR ADDRESS P.O. Box 133 CITYISTATEIZIP Fscalon.CA 95320 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 C-61 D-09 Other NUMBER 871)761 EXPIRATION DATE 111/31/2020 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED Use DomestruPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> If dieererx from Owrvr er 4yl— arrw o a rna a m r <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) Aofwells SoilBonng(s) rotb""' XGeotechnical._8_.00b—irs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casio <br /> (WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> IProposed Well Depth 5 to 20 R Excavation 4 1/2 in diameter Open Bottom Gravel PaddGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth n <br /> Well Casing Diameter in Thidmess/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depthfull depth It \Neat Cemenl(94 ID bag/5-10 gal water) Sand Cement _ sack m[x17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method \Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width n Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submers,ble Turbme Other HP Pump Set fI Standing Water Level R <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 COMPENSATI N LAWS. <br /> MINIM OU R4 ANCE NO E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Oviiner/Operator DATE 03/14/18 <br /> R,E <br /> CFjvjep <br /> 11 AR 19 ?418 <br /> OAQu <br /> RON/N OO�Nry <br /> TH[)FpAR MINT <br /> _ PAR HENT U E OALY <br /> Application Accepted By Date Area Employee IDS <br /> Grout Inspection By Date c`t JC PECIAL Well Permit <br /> Pump Inspection By Date �.J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 'A /A f-,, I A-0 11 — <br /> PESC Received Check Amount Permit <br /> Codes Info By Pemitted Dale Service Request S Invoice A Well IDA <br /> E-()411015 WELL[PUMP PERM-T <br /> 4rdOn 2 <br />