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W <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 93203 -6232 (209)4683420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/elid EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1OG27 Copperopolrs CiTyll Stocldon 95215 <br />(CROSS STREET Hest Rd APN 1030402 _ PARCEL SIZE 4 ­SLAND USE APPLICATION # <br />NAME Jose Moreno <br />PHONE <br />Ovm ER ADDRESS 10027 COpperopoli Rd CrTY/STATEll StOcldon, Ca 95215 <br />CONTRACTOR Golden State Irrigation S Pump Services PHONE 209-943.7774 <br />CONTRACTOR ADDRESS 4500 E Fremont CITYISTATE/ZIP Stockton. ca 95215 <br />PHONE <br />SUBCONTRACTOWCONSULTANT ADDRESS CITYISTATEIZIP <br />LIcENse D G57 OKC-61 C D-09 C Other NUMBER 979333 EXPIRATION DATE 12/31122 <br />BILLING PARTY: = OWNER 3 CONTRACTOR D SUBCONTRACTOWCONSULTANT <br />DoMES11C WELL SAMPLING: General MineralIColiform Bacteria (4391) ❑ Dibromochloropropane (4392) L1 Arsenic (4393) <br />INTENDED USE Y DomestrcJPnvate ❑ hngabon/Agncultural C Industrial C Water Quality Monitoring C Sod Sampling/Characterization <br />Public Water System <br />IT :101 nl tram Owner Wale System Name Contad Name w Phone Number <br />TYPE OF WORK G New Well D Replacement Well C Well Alteration/Modification C Other <br />C Monitoring Well(s) #of wens CSoil Bonng(s) 0 c bwf gs ❑Geotechnical eorbmrwz <br />C Out-Of-Semce Well C Out Of -Service Well Renewal ❑ Cross Connection Repair <br />C Raise Well <br />Drilling Method C Mud Rotary ❑ Air Rotary ❑ Auger Cable Tool C Push Point ❑ Other <br />Proposed Well Depth_ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth It <br />Well Casing Diameter _ in ThicknesslGauge/ASTM Sched C Steel C Plastic C Stainless Steel ❑ Other <br />Grout Seal Depth_ft C Neat Cement (94 It, bill 10 gal water) ❑ Sand Cement sack marl gal aster <br />C Bentonite (20% solids) C Other <br />Grout Placement Method �: Pumped C Free Fall D Other C Retardant/ Accelerator (name) <br />PEDESTAL Installed By C Driller C Pump Contractor C Other <br />C Concrete Pedestal CDimensions Width ft Length ft Thick in C Christy Box C Stove Pipe <br />PUMP ;t Scbmel Turb.ne C Other HP 3 Pump Set 180 ft Standing Water Level 60 <br />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. 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. <br />tAlt fy��jLy/j 1/48 HOUR % 1VA[�NjC�fENOTICE REQUIRED FOR CT /Nl - PLEASE CALL (209) `953 7669`7 <br />SIGNED L J�`� �' `a \ `�\) 1 TITLE.DATE <br />EP R T M E N T USE LY <br />Application Accepted By Data Z-`%% <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Sal Boring lgpWecLon By Date i - <br />S <br />` EmployeelD#��7�7� <br />� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />ttructed We�DRpth <br />-a a ��—,�.�,� - ---- ry i r ,•>~ ., <br />IN <br />a <br />D <br />S <br />N <br />PE SC Received CheckW Amount Date Permltl <br />Codes Into asFt Remitted Invoice# Service Request <br />` <br />Well 10# <br />EHD43-0e ill -4 t 3 [QC) b0 It , L% 11/��/��► wELL,PVNP PLR1Ai, <br />� <br />-T q 3 <br />