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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMITCALL <br />1 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1202 i LAM IPV) C-�.0 1 CL' 13 L -L ,.-,, �-7 CITY/ZIP /�� oc 1�I-n r 1 I I <br />CROSS STREET C h'\ t�Gtt�C�[ 1�� APN If �2 C _Sl.. �i T PARCEL SIZE I LAND USE APPLICATI�O}NI ,#/ n <br />OWNER NAME I'Or �- CC' S�C7L�}-y'�� PHONE <br />1 2-�)cC - // 7L 0 <br />OWNERADDRESS .��U1 (k) (r,.)u5I'�1 roc [/J�'-\ SCP+ CITY/STATE/ZIP-5+CIS <br />'1 <br />CONTRACTOR _' G �1I1\ ` PHONE 9z5-313--5802 <br />CONTRACTOR ADDRESSXl nII�iVv-)e <br />CIT <br />-1 Y/STATE/ZIP 01 - ( `4553 <br />SUBCONTRACTORrru ',l`el(\ '\\ �\ �:\<ii\L'J%-1 l PHONE f/--�'`�v5%--���- <br />SUBCONTRACTOR ADDRESS S5 I�GISD�'1'i 1�- I �� CITY/STATE/ZIPpp <br />LICENSE X 1 -� C-57 C-61 f''. D-09 '. Other NUMBER / EXPIRATION DATE 01 1 3 I I C) (L7 <br />GEOGRAPHICAL INFORMATION: Coordinates X - 1 2-) 3[a- ,L Y21 (r:' ..� I Township_ Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial � Water Quality Monitoring 9 Soil Sampling/Characterization <br />i Public Water System <br />If different from Owner: water 5yStern Name UontaCt Name or Phone NUMber <br />TYPE OF WORK I I New Well :I Replacement Well I i Well Alteration/Modification K Other CVT <br />f l Monitoring Well(s) # of wells i Soil Boring(s) a of borings X Geotechnical 5 n o1 Donngs <br />Out -Of -Service Well ] Out -Of -Service Well Renewal Cross -Connection Repair <br />II New <br />Drilling Method rl Mud Rotary 1 Air Rotary L' Auger Cable Tool Push Point X Other CVS <br />Proposed Well Depth'" 100 ft Excavation in diameter i I Open Bottom Gravel Pack/Gravel Size in diameter <br />! i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad I Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft X Neat Cement (941b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) iOther <br />Grout Placement Method f. Pumped Free Fall X OtherI Cx ii Retardant / Accelerator (name) <br />PEDESTAL Installed By : Driller [ Pump Contractor Other <br />.I Concrete Pedestal: ]Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP ; Submersible Turbine i Other HP Pump Set ft Standing Water Level It <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. 1 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 COMPENSATION LAWS. <br />pr, <br />R�CE��E <br />SEP N Goin <br />..' NDc ROUNpFF p' { Iication Accepted By <br />E OF R <br />N�\To <br />Grout Inspection By. <br />ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)) 953-7697 1 <br />'A'ATITLE Glo' I I�t1 CGr" DATE l ��r )2c 1 7- <br />DEPARTMENT USE ONLY <br />Q (�� <br />Data q ') S`/ ? <br />Date <br />Area c�� K Employee ID# <br />D SPECIAL Well Permit <br />VE <br />CEfD <br />2017 <br />cry rAL HEALTH <br />/SERO�FS <br />t 'I �k jF- ; <br />re or, e _ 1 g , 4Tt^r L <br />PE <br />Codes <br />Sc Received -�IW <br />Info B Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />'1391 <br />esu <br />�3q <br />WN -0,5 Iff <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />