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�t <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1068 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 <br />NON-REFUNDABLE PERMIT CALL 2V09 9p53-7697 FOR INSPECTIONS 1 YEAR FROM DA/TES ISSUED <br />G g E' L11� A-�y <br />r�J, <br />r�\EXPIRES <br />~, (vin � o � <br />Joe ADDRESS lT 1 ` <br />CITY/ZIP 15 <br />jI 1� <br />CROSS STREET N 1;('-4 nn -1- R V- APN `3U / -C170-- 4y PARCEL S¢E LAND USE APPUCATION 8 <br />OWNER NAME elson MCjo fi pd O <br />/ <br />--75128 <br />PHONE L' <br />(�N <br />OWNER ADDRESS �`1'/ 3 -CI I t f 1 C\` C 4- <br />/�SR�Cjj <br />CITYISTATE/ZIP C 1-1 I� I 15 J <br />p <br />CONTRACTOR J C111 ItI D'r`/111 t() <br />/C/�/�•'1 �C, <br />PHONE 7�P�q - 2 77 t <br />J <br />CONTRACTOR ADDRESS I C ' ✓6 /` 4 '^ <br />CITY/STATE/LP � ' 14 ` A <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYYnlSZTCATE/ZIP <br />LICENSE C-57 C-61_' D-09 _ Other <br />NUMBER :xi -t J S 5 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE DomestictPrivate s Irrigation/Agricultural ' Industnal Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />Ir different from 0— Water Sy5tem — Contact f4a— or Phone Numb., <br />TYPE OF WORK New Well Replacement Well L Well Alteration/Modification Other <br />L Monitoring Wells) # of wells C Soil Boring(s) # or bonrp - Geotechnical M of borings <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 Casino <br />Drilling Method �K Mud Rotary n Air Rotary Auger Cable Tool - Push Point - Other <br />Proposed Well Depth -Vo III Excavation 2 in diameter Open Bottom )Gravel Pack/Gravel Size I1d in diameter <br />i- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched C I AL r- Steel A Plastic Stainless Steel Other <br />Grout Seal Depth IUC It - Neat Cement (94 lb bag/5-10 gal water) )[ Sand Cement I C' sack mixl7 gal water <br />i. Bentonite (20% solids) Other <br />Grout Placement Method 1V Pumped : Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By /X, 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 :. `, ft Standing Water Level Z : 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) 953-7- 1 <br />6797 <br />SIGNED -+c/' -ll / `i `���� �� TITLE '-J , i i. lit <br />C J , : ,� f , j 4 DATE 5 / 2 / 1 a' 1 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />4Ec MFNT <br />E/VEL) <br />4AY 27 2021 <br />RONN <br />�COUNT <br />H DE ARTMENT <br />PA TMENT U E 0/41-Y,���1C/ <br />Date �A Area Employee lD#� G <br />Date v �LI 7 PECIAL Well Permit <br />/J: Date 0 V• A WAIVER Received (�/ <br />Date Constructed Well Depth 3 z ft <br />ow <br />EHD 43-05/ , I' WELL /PUMP PERMIT <br />4/30/12 W ,� s1�> int P 0 8 4-09-7 <br />,> O <br />