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ON-PtH <br /> ' ANCWNTYENNRONMENTALHEALTH DEPgR WELL/PUMP PERMIT <br /> .EFUNDABLE PERMIT 1868 EAST HAZELTONAv NUE-STOCKTON CA 95205-(209)468-3420 <br /> CALL 209 953-7697 FOR INSPECTIONS <br /> EXPIRES 7 YEAR FROM DATE ISSUED <br /> 'ADDRESS Lia crcrJ CGa+YFK'SFr(IND tf/SS 17AUFL qV£' w <br /> arvZP '>-v L.tro rJ I95Zo� ,� <br /> rt033 STREET Ip GEN 1I ryo LT T It-lL1" -P .. <br /> APN�PARCELSIZELgNO USE APPLICgRON# a <br /> DwNER NAME I-INCo C _�NU12ehr MENTgI,- I <br /> -T R,V5 PHONE <br /> OWNER ADDRESS _ 30r1 J� Gp LJP �e,.TAt, Y2 V4 $ -6 Z.1 <br /> CoxrRAcroR �J <br /> G2nA - V CITY/STATE2iP fzAr Ay& t 2voJA (q Gy S6 U <br /> _ a b I I I N C, <br /> CphrrRACTORADDRESS Zs 2S " ��,11 !-� PHONE <br /> _ AioMA$ TA1ZK I��, VG CITY/STATEMP SAfRM JI � t1 <br /> , yE 3 <br /> SUBCONTRACTOR Co'' F V , '1 a I�--/ C <br /> E.NV,2oN M C^r q L <br /> BDBCDNiapCTOR ADDRESS 6821 81r1II. St PHONE 916-760-7641 <br /> clniSTATHZIP Rio Linda CA 95673 <br /> LIcENSE M.C-57 ❑C-61 ]D-09 = Other <br /> NumBER 913194 Ell,lRARONDATE 4/30/2017 <br /> GEOGRAPHICAL IxFpRMgTION: Coordinate,X 3`L. O(126$ Y -1ZI 3136SD <br /> INTEND D USE = DomestiUPmale ]InigatloNAgricuWral O Industrial Township Z. Range 6 Secpon?1i <br /> - Public Water System R'Water Quality Monitoring ❑Sall Sampling/CharadelizaHan <br /> IlEIRtteM fmm Ownar. <br /> a er Te em ma <br /> TYPE OF WORK - New Well a e"1e pf m um <br /> -Replacement Well g WeII AlteraBoNModigcaHon $Other F P <br /> Wtl( PZ-615 - Monitoring Well(s)__#of wells USoil Boring(.) O.fwd,. LACfI+i E.�T wE43 K <br /> -Out-Of-SeMce Wen U GeOlechnical softens. <br /> ❑Out-Of-Service Well Renewal ❑Cross-COnneCHen Repair <br /> - New Pum -Pum Re l8MMSnt n Pum Ra air <br /> WELL ODN$TRBCR N n Raise WeII Casin <br /> Ddng M@Nod -Mud Rotary -Air Rotary -Auger n Cable Tool n push Point r Other <br /> Propased Well Depth ft Excavation <br /> in diameter ]Open Boftom ]Gravel Pack/Gravel Ske <br /> _ Conductor Casing_in diameter / Conductor Casing Dephl in diameter <br /> Well Casing Diameter_In Thlckness/Gauge/ASTM Schell g <br /> Grout Seal Depth ft UNeat Cement(941b bag/610galwete Steel OPlastic ❑Stainless Steel DONer <br /> = Bentonite(20%Solids) ❑Other U Sand Cement sack mixt/gal water <br /> Grou[Placement Method D Pumped O Free Fell D Other <br /> Retardant/Accelerelor(na <br /> ] me) <br /> PEDvav TAL In6ta11ed By L Dnllef U Pump Conuador <br /> Concrete Pedestal-Dimensions:Width - Other <br /> �ft Length flThick in -Christy Box -1Slove Pipe <br /> PUMP - S b ibl C T rbi _n <br /> i HEREBY CERTIFY THgT I HAVE PREPARED THIS APPLICA'RON AND THAT THE WORK WILL BE DONE INlnq CaORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT qN0 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I qM IN COMPLIANCE WITH ALL <br /> WORKERS C PEN ATION LAWS. <br /> MINI HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963-7697 <br /> SIGNED <br /> rinE CFO DATE 6/15/15 <br /> yMENT <br /> FryFO <br /> q �ve <br /> /Ara <br /> k <br /> DEP RTMENT U E/ONLY <br /> Application Acte d Date�� ��s//�S— <br /> Grout lnsp - Date El Nes Employe <br /> Pump Inspection By ElSPECIAL Well PefxTitlt <br /> Dale 11 WAIVER Received <br /> Soil Boring l�j �ction�B <br /> COMMENTS Data Constructed Wap D pN <br /> ft <br /> _�!I.EZ7-r ani� GKPf � JJniw�i- � A <br /> PE SC Received Che Amount <br /> Codes Info B h R@milted Date PermlN <br /> 3 Service Re east# Invoice# Wali ID# <br /> l3 p_ r6 S266�� <br /> ENO<a se <br /> anal. <br /> WFL-/ PPERMIT <br />