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�v�l'ft�t` <br /> ` -'2d S- 7 WELL/PWP PERMIT <br /> SAN JOAoutN Courm ENviRoNMEHTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS, EXPIRES 1 YEAR FROM DATE ISSUED <br /> Cm/LP <br /> JOB ADDRESS iJIy]J m <br /> LP/NE Rte <br /> CROSS STREET U r/ APN PARCEL SIZE LAND USE APPLICATION$ m <br /> OWNER NAME ! ur�r<<v ,(� 'V kAV A�''���i//A PHONEA � <br /> OWNER ADDRESS 1 y /•��•��J —`�' CITY/STATE/ZIP zoUf I <br /> CONTRACTOR )s ) )mp SE-'y/ce PHONE a017 ;f'S-��g'9 <br /> CONTRACTOR ADDRESS �Oo62 til;Cal HOPE 'et CITY/STATEIZIP_ <94c-7— CAI '7,595. <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY//STATEIZIP <br /> ! <br /> LICENSE C-57 i!C-61 !!D-09 !!Other NUMBER bEXPIRATION DATE 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE PCDomestic(Private !!Irrigation/Agricultural Industrial !Water Quality Monitoring !!Soil Sampling/Characterization <br /> Public Water System <br /> I differem from OwnerWfe, em ame Cwtact Narne or Phorre Nurnber <br /> TYPE OF WORK !!New Well !!Replacement Well i!Well Atteration/Modification !!Other <br /> i Monitoring Wells) It of wells :!Soil Boring(s) <br /> a of borings ,i Geotechnical of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair <br /> !i New Pump i!Pump Replacemen Pump Repair !!Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i!Mud Rotary !i Air Rotary !!Auger !i Cable Tool !!Push Point i! Other <br /> Proposed Well Depth ft Excavation in diameter i i Open Bottom i!Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thidmess/Gauge/ASTM Sched !!Steel !!Plastic i!Stainless Steel !i Other <br /> Grout Seal Depth ft !!Neat Cement(94 lb bag/5-10 gal wafer) !Sand Cement sack mix/7 gal water <br /> :i Bentonite(20%solids) !!Other <br /> Grout Placement Method !i Pumped !i Free Fall !!Other i!Retardant/Accelerator(name) <br /> PEDESTAL Installed By i!Driller !i Pump Contractor i i Other <br /> !i Concrete Pedestal Dimensions:Width ft Length ft Thick in !!Christy Box i!Stove Pipe <br /> IEW—P V(Submersible!i Turbine !!Other HP • Pump Set 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TrTLE DATE <br /> PAY�EN� <br /> RECEIVE <br /> JMJIRO MES7 �} y jJyyyy <br /> HFI�LTH DEPAFi <br /> --170mmm7mmmmmmmmmmm Ell IMM ME <br /> 3 VEVTAL F,'t:rH <br /> rO EP �TEI SE O LY <br /> Application Accepted By to Area_ Employee ID#J� 17 <br /> Grout Inspection By Date 1SPECIAL Well Permit <br /> Pump Inspection ByDate r �`� WAIVER Received <br /> Soil Boring Inspection BY Constructed Well Depth R u S Aw <br /> C MMENTS i QUI <br /> Ito, fit <br /> PE SC Received Ch Amount PmiU �ar� <br /> er <br /> Date Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> D /71y/ .`u 4111-7 I-7 SRb070l oo VII A2�� <br /> EHO 43-M WELL/PUMP PERMR <br /> ammm <br />