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Epi c9 -75S <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />Ivan-KEFUNDABLE <br />Area U Employee ID# <br />I;ALLL (LU9) 95S -/b97 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />Grout Inspection By <br />pP-E7R�MII�T <br />00 <br />28700 <br />G <br />0 SO IJ 1e'S <br />/ <br />Go <br />It � <br />Joe ADDRESS <br />r <br />• <br />-WC'. <br />CrTYi/JP If <br />c/'1 p / <br />CROSS STREET <br />j <br />L II�1- ,l 1 <br />� <br />r ., <br />APN <br />� <br />p <br />PARCEL SIZE �`�- L"� LAND USE <br />APPLICATION # <br />OWNER NAME <br />V4IID <br />e <br />I� c V"J <br />PHONE <br />OWNER ADDRESS <br />SgS.3 <br />/j <br />N Wets- love <br />CITY/STATE/ZIP Ll�f <br />Int /� �-f�J <br />nn �1.53/-ya't <br />CONTRACTOR <br />�AIOA <br />orf 11irA Cay <br />IIIc. <br />`cA <br />(.53 i)•�662-6-775 <br />CONTRACTOR ADDRESS ZD <br />I:en�&441i <br />/ Ayr, <br />I ,PHONE <br />CITY/STATE/ZIP WA,dI <br />Nt(A V T 4 -TA qS <br />, <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE Jt C-57 C-61 I D-09 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER _11_112 - EXPIRAnON DATE 7/31 1201 <br />GEOGRAPHICAL INFORMATION: Coordinates X - 121. I %6yq Y 38. 24q.314 Township _ Range Section <br />INTENDED USE I Domestic/Private )f Irrigation/Agricultural I Industrial Water Quality Monitoring I I Soil Sampling/Characterization <br />Public Water System <br />If different from Owmec water YSIBM Name u -tact Name or one um r <br />TYPE OF WORK )t New Well f-, Replacement Well P Well Alteration/Modification Ii Other <br />Monitoring Well(s) # of wells L Soil Bonng(s) If of borings Geotechnical of borings <br />Out -Of -Service Well P Out -Of -Service Well Renewal Cross -Connection Repair <br />X New Pumo f" Pump Replacement r'. Pump Renair I Raise Well Casino <br />Drilling Method V Mud Rotary I : Air Rotary i i Auger .I Cable Tool I Push Point , Other gevefse A:;, f e l/ <br />Proposed Well Depth — IM ft Excavation -29 in diameter Open Bottom X Gravel Pack/Gravel Size 8X16 in diameter <br />Conductor Casing in diameter / Conductor 7Casing Depth ft ®j <br />Well Casing Diameter In Thickness/Gauge/ASTM Schad 'rSteel I' Plastic Stainless Steel Other <br />Grout Seal Depth0ft I I Neat Cement (94 lb bag15-10 gal water) Asand Cement 10,3 sack mixAllal wa <br />Bentonite (20% solids) II Other 'A <br />Grout Placement Method $ Pumped L Free Fall 1 Other Retardant / Accelerator (name) Alk t <br />PEDESTAL Installed By , Driller V Pump Contractor ❑ Other <br />Il I Concrete Pedestal Dimensions: Width ft Length ft Thick in I Christy Box Stove Pipe <br />PUMP . SubmersibleX Turbine I i Other HP Pump Set ft Standing Water Level ft <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By ti '� L Date Z %t `7 <br />Area U Employee ID# <br />L' <br />Grout Inspection By <br />Date <br />D SPECIAL Well Permit <br />Pump Inspection By <br />Date <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />It <br />COMMENTS T,Kxk :i\ SV\i,L �1v r�.yt� <br />h ti:,.� <br />�� 1yr \S C `lci�l LL'tL1—Cc-�� <br />>hS A.'%c`�.t 4.- r r yA- i S im> S c -Li t <br />f Cti <br />PE SC I Received Chea Amount Date Permit/ Invoice # Well IDM <br />Code! Info B has Remitted Service Re uelt # <br />:HD 43-06 <br />4/30/12 <br />