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, . I ? <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> • <br /> JOB ADDRESS 3301 i/�: Nf .4r ROAD -- CITYIZIP STOCKTON / 95206 <br /> . <br /> CROSSSTREET MULLER ROAD APN 162-120-01 _ _PARCEL SIZE 155.87 Ac.LAND USE APPLICATION#_,.-... 0 CS ■ a <br /> OWNER NAME LORY C. MUSSI INVESTMENT, L.P. -a <br /> CD <br /> OWNER ADDRESS 43(6�]2�MULLERR RROj�ADy1/_, —_ CITYISTATEIZIP STOCKTON /tQCA / 95206y{�� .dW.��' • <br /> CONTRACTOR b��!1S��U�"`�_ Wi PHONE,. �1 4 Q <br /> CONTRACTOR ADDRESS n o -"_" r 020� CITY/STATEIZIP__ ,b.0L1].k'.t)--CA_114_ O • <br /> ___�_ _ � Q .. <br /> SUBCONTRACTOR .. PHONE_ CDC <br /> CU <br /> SUBCONTRACTOR ADDR SS-_—____----------------------------__— CIITYY/$TAT`EI�ZIaP_{r,________—____— .( ,(` C -CD ®M <br /> LICENSE C-57 C-61 D-D9 Other..................._...._.............. ... NUMBER,_.._p, u....�(..:V EXPIRATION DATE �'1 __O� �j {� 7. `! 1 <br /> 6319364 2153835 1N 6E. 29 S <br /> GEOGRAPHICAL INFORMATION: COordlrgates X-_----.__________ Y______--_- Township_____ Range__ Section--_ '[; '�• Q <br /> INTENDED USE Domestic/Private I Irrigation/Agricultural X Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> --------- y-- ---- ---- - - --- ----- --- . <br /> If dittererd from Ownec -Oir��stem�7ame Eontacl flame or Pfiona P7umher -- r'1- � <br /> Cp -.S- <br /> TYPE OF WORK X New Well l Replacement Well Well Alteration/Modification Other <br /> ocaon h <br /> p k of borlrgs p or borings <br /> Monitoring Well ------#of wells Soil Borings) _ Geotechnical ______ <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair > <br /> New Pump Pump Replacement Pump Repair Raise Well Casing to <br /> WELL CONSTRUCTION - P) <br /> O <br /> Drilling Method Mud Rgtary)( Air Rotary Auger h Cable Tool Push Point Other o' <br /> Proposed Well Depth___. _� ft Excavation .._� in diameter Open Bottom Gravel Pack/Gravel Si-41Y-7 in diameter <br /> Conducts Sing, in diameter ! ConductorMn Depth <br /> Well Casing Diameter ,e•�in ThicknesslGauge/ASTM Sched�// Steel Plastic 14 Stainless Steel Other__ _ <br /> Grout Seal Depth_-- 'V_. ..ft Neal Cement(94 Ib bag/5-10 get water) Sand Cement__-91,.. ----sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped 1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set it Standing Water Level it <br /> 1 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 WITO THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION AWS. <br /> MINIMUM <br /> 2_4_ V_._AA /fTVVEQUIRED FOR IvP ` ''n�Im�� PLEASE CALL(209)953-76t7 <br /> SIGNED TITLE _ —D <br /> ____ -- ------- <br /> X <br /> ._ <br /> 1 <br /> ISI G I S <br /> M4 I <br /> . a N 16 <br /> PES 5 . <br /> F'2►rmi - <br /> ��� be <br /> I <br /> by Env I <br /> I hill <br /> L_Jj 11 <br /> 0 1_�, I <br /> DEPARTMENT TSE ONLY 2IA }— <br /> Application Accepted By -r� ' Date 7� _ll((_.� _ Area.__._ 1__G_1_ EmployeelD#_l_ ��5 PAYMENT <br /> Grout Inspection By---_-----_----_-----____ Date_ ---____ SPECIAL Well Permit RECEIVED <br /> Pump Inspection By__ _—_ Dale--------------- WAIVER Received <br /> Soil Boring inspection By_------ ._...__.._... Dale . _ Constructed Well Depth it MAR 17 2015 <br /> COMMENTS <br /> _._. .......... .......................... —_----- -- OXQUIN COUNTY <br /> -__ _._. SA Et3ZRONMENTAL <br /> PE SC Received Check#I Amount Date Permit/ Invoice# WellID# RTMFN <br /> Codes Info B Cash Remitted Service Re nest# HEALTH DEPA <br /> Vita 3 17 l <br /> EHO47-06 WELL!PUMP PERMIT <br /> 417012 �� OVA / JOB. NO. 2015-24 3-1 <br />