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Y� WELL/PUMP PERMIT <br />SAN JOAQUIN COUNT' ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) rt68-3 <br />i i.. <br />NON-REFUNDABLE PERMIT n CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEUL <br />J <br />JOB ADDRESS S�a E /—�� CITY/ZIP Lc%A'-0 <br />CROSS STREET M C 14SI L% /4VX APIN ji.q.3 3,2 10/rd PARCEL SIZE -S741ILLAND USE A'PP.CATION Ila( <br />OWNER NAME SLtkk,AQIN a -A f•lt PHONE Urf- y7J-�C5) <br />OWNER ADDRESS _ DIP to --A' " J41 Ii- {w{.�-( CITY/STATEMP E !�&A /t CA" -� is -v/ <br />CONTRACTOR �'�lQ- Aid.. aA :0,4v- t PH-O/NE Zt�7-3QY2f7-[3J70/ <br />CONTRACTOR ADDRESS `7 00 Zi14-rt1-1W Purz,,. CITY/STATEIZIP 4aK r. CA 7 �^ 7a <br />SUBCONTRACTOR _61U PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZlP <br />[LICENSE W-57 C-61 D-09 _ Other NUMBER &(P� ExPIRAnoN DATE J <br />GEooRAPwcAL INFoRMAnow Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic/Private Irrigatton/Agricusurai Industrial Water Quality Monitoring XSoil Sampling/Characterization <br />Public Water System <br />II drif.—t kom Owner Weller System Name CDIWd N— or ro Number <br />TYPE OF WORK New Weil Replacement Well Well Alteralion/Modification Other <br />Monitoring WeN(s) N of wells Soil Boring(s) r m bonrgs XGeotectnical _`Ls or Iwnrgs <br />Out -Of -Service Was Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method )CMM d Rotary Air Rotary )CAuger Cable Tod Push Point Other <br />Proposed Well Depth -T-SD It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 /b bagr5.10gal wafer) Sand Cement sack mrxf7 gal water <br />-- <br />Bentonite(20%solids) tNOftw *** GIsIK�4" <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />Installed By Driller Pump Contractor Other <br />COnersh Pedestal Dkn trialons: Width It Length ft Thick in Christy Box Stove Pipe <br />Qum Submersible Turbine Other HP Ptxnp Sel 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 AM IN COMPLIANCE WITH ALL <br />WORKERS CO NSATION LAWS. <br />MIN OUR A ��/yryyryj�r��Jrp NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL (209) 963-7697 <br />SIGNED •r r —�1 TITLE�(N Agte.&L{ DATE Z <br />Application Accepted By / <br />Grout Inspection By <br />Pump Inspemon By <br />Soil Boring Inspection B <br />COMM TS <br />PE SC Received 1 <br />Codes Into B Call <br />D <br />0 <br />G <br />('I'.A 4 ' <br />DEPARTMENT <br />SEIroNLY <br />( <br />(S U hn <br />a� <br />Date <br />l Area Employee IDI <br />Date <br />SPECIAL Well Permit <br />WAIVER Received <br />e <br />Constructed Well Depth <br />ft FAW&VT <br />RL ECENED <br />Arnouffit <br />PerTiI <br />Invoice N <br />Well IDN F i ,3 17 2015 <br />Remitted <br />Service <br />Service Request N <br />I JOAQWN COUNTY <br />hLTH ENS OMMAL <br />DEPMIRTMW <br />EHD 43-M <br />WELL !PUMP PERMIT <br />11"17 <br />