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WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468-3420 NON-REFUNDABLE PERMIT www.sigov.orailehil EXPIRES 1 YEAR FROM DATE ISSUED C JOBADOREss t <"��}� i2C� 114.-t, i;lo,4:s'� i�� ( �'ir.;( mZP r=Cic{gin (, 4 Z.�17 li ao 1;1'73 �� il'bo13 35 acres s CROSS STREET L'V�G' -+O r �1 APN)]390,90c I/l�j PARCEL SIZE LAND UBE APPLICATION#/, C( p Om+ERNAME L[� OI� �/r,)PQP -fir ifO(.(b PHO . (/��/O I � SY� f/Q��2- Y^ OWNER ADDRESS I 0 '�0 X >14 Ir ( '/ CmISTATEMP 5P0 y t A NC , �✓" ` , CONTRACTOR 1 1?,f r oro n 1,tm,,44 l�(r ri/� 1 f`�-, PHONE (Z-q)'6-7—;T-1 I CONTRACTOR ADDRESS L Y n G't K �.( i 0. J tl _ Cm1STATEILP L 0 Gt CA , '5 24c SUBCONTRACTOR/CONSULTANT J l'✓1 Q Q S .jQ✓Q_ PHONE LI ^ A SUBCONTRACTORICONSULTANT ADDRESS �n�C'i ALS GL bO✓e- CCm1SLTA/tyTE/LP %�`� s �F,OV�-- LICENSE C-57 C-61 0-09 Other NUMBER `' �v 1 0 1 EXPIRATION DATE r / f/ !• /y BILLING PARTY: OWNER XCONTRACTOR - SUBCONTRACTOR/CONSULTANT DoMEsnc WELL SAMPLING[ General MineraltColiform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE DomestictPnvate Ifrigation/Agricultural Industrial Water 0ualdy Monitoring j(Sod Sampling/Characterization Public Water System It diNerenl 6°rn Owner Waley System Name Contact Name m Phone Number TYPE OF WORK New Well Replacement Well !.I Well Atteratlon/Modification Other N of Monitoring Wells) #of wells FI Soil Boring(s) N of 0on"9' x Geotechnical 2 born 9s A Y Out-Of•Servlce Well U Out-Of-Service Well Renewal Cross-Connection Repair New Pum Pum Replacement i Pum Repair Raise Well CasingC V/rA(7- ^ WELL CONSTRUCTION \O Drilling Method Mud Rotary Air Rotary X Auger- Cable Tool Push Point Other PR Proposed Well Depth)5'"¢S K Excavation 'I- = in diameter Open Bottom Gravel PeGJGravel Size in diameter /j 2 Conductor Casing in diameter / Conductor Casing Depth ft Sq NJ, Q 2020 Well Casing Diameter inThickness/Gauge/ASTM Sr had Steel uPlastic Stainless Steel Other ,(,) Grout Seal Depth fl X Neal Cement(94 to bag/5-10 gal water) Sand Cement sack mix At N (� Bentonite(20%solids) Other DFPq O,4 n �TY Grout Placement Method q Pumped X T Free Fall Other Retardant/Accelerator(name) E/V PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal Dimensions.Width fl Length ft Thick in Christy Box Stove Pipe PUMP Suomerslble Turbine Other HP Pump Set A Standing Water Level it I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48/HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED ( �It<(tea, PCACI.tTITLE S-tn En in DATE Pr Za Z-o Ll I V DEPARTMENT USE ONLY / Application Accepted By �� r�"" Z Z- Date 7 J J Area 5�"C"k�"Employee ID# Grout Inspection By Data C' SPECIAL Well Permit Pump Inspection By Date C' WAIVER Received Soil Boring Inspection By Date Constructed Well Dap th It ' COMME,Ts� .� �� i15: 17,n 1) rl :�c;f O ' P,PC tvI_ r$ Pi art. • �w v 111'>S 1� 11 fc17 L'(( C 1 jN r in �y/pP�'l. PE SC Received ChsckNl Amount Date Permit! Invoice N Well IDN Codes Info Cash Remitted Service Re nest N .r S Z EHD41-06 6111R019 ''EU/PUMP PERMR