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�t <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 /> Joe ADDRESS ffIG g E'1�r,tt�SP� Ane- CITY21P '—\ CSM`RC1 (�1 <br /> CROSS STREET I� �r�A11"+- 1� V• APN c5U /-C17c1-Q!� PARCEL SaE LAND USE APPUCATTIION# / Q <br /> OWNER NAME (Nelson MGf�pd In, PHONE L;IoG/�S,2ci --75 GO •' <br /> OWNER ADDRE33(:O ,� y�(1 I li'�f' 1 C\` C /� CITY!$TATE/LP �' \I ! /�'1 (J C512 <br /> CONTRACTOR \J 'Al If I 11D ir'l 11 if)� /PHONE.- G - a 77 9 <br /> CONTRACTOR ADDRESS f C ' ✓6/` 4'q CITY/STATE/ZIP l��)� � CA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYYnISZTCATE/LP <br /> LICENSE C-57 C-61 _'D-09 _Other NUMBER :xl-t J S 7 EXPIRATION DATE / -3` <br /> - <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DomestictPrivate -j Irrigadon/Agricultural Industrial Water Quality Monitoring - Soil Sampling/Characterization <br /> Public Water System <br /> If different from 0— Water Sy5tem — ane me or ne N-15.1 <br /> TYPE OF WORK New Well Replacement Well L Well Alteration/Modification Other <br /> L Monitoring Well(s) #of wells C Soil Boring(s) If of boor -Geotechnical M of borirW <br /> Out-Of-Service Well r Out-Of-Service Well Renewal Cross-Connection Repair <br /> XNew Pump i i Pump Replacement C Pump Repair .-,Raise Well Casing <br /> WELL CON3TRVC7ION <br /> Drilling Method�K Mud Rotary n Air Rotary Auger Cable Tool - Push Point - Other <br /> Proposed Well Depth _ft Excavation in diameter Open Bottom `xGravel PacklGravel Size 'JA in diameter <br /> i-Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched G I AL r- Steel A Plastic 7 Stainless Steel Other <br /> Grout Seal Depth !)C. ft Neat Cement(94 lb bag/5-10 gal water) )t Sand Cement 1 C' sack mixl7 gal water <br /> i. Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By/<,Driller ',,Pump Contractor, -i Other <br /> �C Concrete Pedestal-'Dimensions:Width > ft Length_L ft Thick in i Christy Box Stove Pipe <br /> PUMP Submersible- Turbine Other HP Pump Set -`rl 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. 1 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 /> .r <br /> SIGNED L l' !,:i.. >' TITLE "J .C C. ?'l C J,:,�C'� DATE C-- l X <br /> C <br /> PAY <br /> . z ENT <br /> h , c <br /> AY 27 2021 <br /> H RoN�N C��NT <br /> + T1 DEARTMENT <br /> _ P A TMENT UA E 07 L Y <br /> Application Accepted By Date 14 Area Employee ID# <br /> Grout Inspection By Date ?•�li� PECIAL WBII Permit <br /> Pump Inspection By J::-: Date Vjj`-j JbtL ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well 10# <br /> Codes Info B Cash Remitted Service Re uest# <br /> 'Wel I A Irv- <br /> EHD 43-05 / WELL/PUMP PERMIT <br /> 4/30/12 �,�SL> oP084 P09`7 <br /> �3po 69 <br /> �(� � 12-(�o07 39-3 <br />