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At4_ CITY/STATE/ZIP CA'. 9 OWNER ADDRESS <br />CONTRACTOR PHONE <br />EXPIRATION DATE NUMBER H C -61 11 0 -09 I Other LICENSE C - 5 7 <br />ft ft Standing Water Level HP 0 Submersible Turbine II Other PUMP Pump Set <br />A <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS \J X •cAi.yt-c <br />Date <br />Date <br />Date <br />A r•J <br />Employee ID# Area I /1kt <br />ft <br />I I SPECIAL Well Permit <br />I) WAIVER Received <br />Constructed Well Depth <br />c;<:(1\- '(,1 1 2 '-J I ci pct) <br />EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />WELL/PUMP PERMIT <br />SAtiJOAQUIN 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 />JOB ADDRESS <br />CROSS STREET APN I (et) )f ° PARCEL SIZE <br />OWNER NAME 1-4-A-- <br />61, crrylz,, (i1- (KTP,t) , <br />LAND USE APPLICATION # <br />PHONE elle'? Qi 3 7 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />PHONE <br />PEDESTAL Installed By 11 Driller n Pump Contractor Other <br />Concrete Pedestal • Dimensions: Width ft Length in Christy Box 1: Stove Pipe ft Thick <br />0 Well Alteration/Modification 0 Other New Well El Replacement Well TYPE OF WORK <br /># of wells Li Monitoring Well(s) <br />XOut-Of-Service Well <br />E New PUMP 1:1 PUMP Replacement <br />E Other El Mud Rotary Li Air Rotary I I Auger E Cable Tool I Push Point <br />Depth ft Excavation in diameter <br />Drilling Method <br />Proposed Well in diameter Open Bottom 'i Gravel Pack/Gravel Size <br />ft <br />Plastic .1 Stainless Steel LI Other <br />Sand Cement sack mix/7 gal water <br />LI Conductor Casing in diameter / Conductor Casing Depth <br />Diameter (e:, in Thickness/Gauge/ASTM Sched ihrf_Steel <br />Depth ft LI Neat Cement (94 lb bag/5-10 gal water) <br />i Bentonite (20% solids) 0 Other <br />Well Casing <br />Grout Seal <br />Soil Boring(s) # of borings <br />Out-Of-Service Well Renewal <br />Pump Repair <br /># of borings Geotechnical <br />Cross-Connection Repair <br />Raise Well Casing <br />WELL CONSTRUCTION <br />Grout Placement Method IJ Pumped El Free Fall D Other i Retardant / Accelerator (name) <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 I AM IN COMPLIANCE WITH ALL <br />WORKE SATION LAWS. <br />48 HOUR IVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE DATE SIGNED :SS32:10CIV 3119 A -c.! 1,13 vC)1P,R0 McTA— <br />I.1EAH DF_PARTMEN1 <br />UNT'l <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />_ Caah <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />It; ti 1 kr 4— i 1 / 22 i1/2-7 i, u e tU37 0 IC' , <br />DEpARTMENT USE ONLY <br />Date 1 /.)N 11)C: