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Contact Name or Phone Number Water System Name <br />LICENSE AC-57 0 C-61 0 D-09 0 Other NUMBER EXPIRATION DATE <br />Range Section Township GEOGRAPHICAL INFORMATION: Coordinates X <br />JOB ADDRESS <br />CROSS STREET TA 17: 1- APN / Z ?Z.(' I93 PARCEL SIZE l"--Vd LAND USE APPLICATION # <br />OWNER NAME d . ao PHONE <br />OWNER ADDRESS 0 e, cii.hoivEL sr CITY/STATE/ZIP S. n C k rdicJ A 9S-20 i Z <br />CONTRACTOR 4. itli4 4 0 Art cidt/ 4 PHONE Z .c. VW ..?/-?.. C,90-0 <br />T7,vE 1 G CONTRACTOR ADDRESS 9-5....0 itot ,E 1-P CITY/STATE/ZIP /t4 4 A 4 91-6757 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />oraztp ~'7oci7beJ, 4 775-- z PA4S/14 a A vE <br />INTENDED Use 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring KSoil Sampling/Characterization <br />Public Water System <br />If different from Owner: <br />46-erPrickW4? <br />PAYMENT <br />RECEIVED <br />APR 2019 <br />IN cOUN FY <br />NMEIs TA, <br />EPAR_ MENT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazehon Avenue -STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED :SSBI1C1Cle allS TYPE OF WORK Other <br />tl of borings <br />New Well 0 Replacement Well <br />Monitoring Well(s) ;it of wells <br />Out-Of-Service Well <br />New Pump 0 Pump Replacement <br />0 Well Alteration/Modification <br />Soil Boring(s) <br />Out-Of-Service Well Renewal <br />Pump Repair <br />S.Geotechnical # of borings <br />Cross-Connection Repair Z-/0 r 5- 0 c•AA/0„,r-A,4 <br />Raise Well Casing <br />9-6 I 0 Other <br />0 Gravel Pack/Gravel Size in dia <br /> ft <br />l g Diameter in Thickness/Gauge/ASTM Schecl 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Wro al Depth 101) P ft lAeat Cement (94 lb bag/5-10 gal watei) 0 Sand Cement sack mix/7 gal <br />Bentonite (20% solids) 0 Other <br />PA Talent Method 0 Pumped 0 Free Fall ;k.I.:Ither flpte4tre„. 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box O Stove Pig ,. <br />PUMP 0 Submersible 0 Turbine 0 Other HP Pump Set ft ttanding Water Level till <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 />WORKERS COMPENSATION LAWS. kle <br />MINIMUM ZHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED ''------------ --- -- TITLE 5' gv-ro A 6/4/4.7me-b9 DATE 4(2 Li -0 9 -/7 <br />UCTION <br />oc.1 0 Mud Rotary 0 Air Rotary 0 Auger <br />9"a I II Depth <br />Conductor Casing in diameter / Conductor Casing Depth <br />ft Excavation in diameter 0 Open Bottom <br />0 Cable Tool 0 Push Point <br />tt <br />ARTMENT U E SNLY LI <br />Application Accepted By . til4..) a— . <br />Grout Inspection By <br />Pump Inspection By <br />Date Areo Employee IDA <br />Date SPECIAL Well Permit <br />Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br /> <br />/4ottf <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Chileft/S M. <br />Cash <br />Amount <br />Remitted Date Vnvoicc Permit/ <br />Service Re. uest § :i. WoII IDo <br />(317 [9) A <br />I # IF Lif .44;2._c <br />0 <br />7 - <br />wp IP si <br />11 i I <br />END 43-06 WELL /PUMP PERMIT <br />8/04/08