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WELL/PUMP PERMIT <br /> `^�•� r �I -O SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.7420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS W`AkLaclY CRY0PP/�I '�" GA 15333 Al <br /> CROSS STREET Union M.5 p APN PARCEL SRE I�IA LAND USE APPLICATION <br /> L# <br /> OWNER NAME Y V0l/Uw/IIIL 05N <br /> L[. P. z�� . LI l� PHONE C� <br /> OWNERADDRESS /III&Am ra Ka •W256 / D CrrY/STATE21P FO Isom./GSA 1560 <br /> CONTRACTOR 1' ooks � FUne5 of NQ.I�-l�1.17L/rr�h t,(A,�` I(tid�•( PHONE 0I/O-J69-%00 <br /> CONTRACTOR ADDRESS` Ill WoOryl6 Ra •z.S o CITY/STATEZP FO Ism,CA 15630 <br /> SUBCONTRACTOR I Yor-W PuMp j We It DIIII(!AX YPHONE(630-/04-Q5AI <br /> SUBCONTRACTOR ADDRESS 1315 &mi`a 91. IJI CRY/SZ <br /> TATEP <br /> LICENSE K C-57 )e C-01 : D-09 Other n NUUMBER 59 ExPiRATIO p TE 1 31 dao l� <br /> GEOGRAPHICAL INFORMATION: Coordinates X 33.0}TR53 Y-121-63M 0 Township_ Range Section_ <br /> INTENDeo USE Domestic/Private X Imgatlon/Agncultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water byStem Name mad! ame or one um r <br /> TYPE OF WORK it New Well Replacement Well , Well Alteration/Modification r Other <br /> i Monitoring Well(s) #of wells I Soil Boring(s) #of bonnga I I Geotechnical #of bodrgs <br /> Out-Of-Service Well I Out-Of-Service Well Renewal I:Cross-Connection Repair <br /> It New Pump i Pump Replacement 1 Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ! Mud Rotary i I Air Rotary i Auger Cable Tool Push Point 1( Other Rayast- QC)TLtA* <br /> 1 <br /> Proposed Well Depth 00 ft Excavation 2.L1 in diameter i Open Bottom Df Gravel Pack/Gravel Size in diameter <br /> 7.Conductor Casing-2-LC-11—in diameter / Conductor Casing Depth T b D ft <br /> Well Casing DiameterAl in Thickness/Gauge/ASTM Sched IN 1'� r Wali YSleel I Plastic I I Stainless Steel Other <br /> Grout Seal Depth 5 0 ft Neat Cement(94 lb bagl5-10 gal water) X Sand Cement 10.3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method x Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller X Pump Contractor Other <br /> i Concrete Pedestal I Dimensions:Width ft Length ft Thick in _.Christy Box ' Stove Pipe <br /> PUMP )i(Submersible I Turbine - Other HP-,I-Q— Pump Set-TED 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 /> N�24 HO VA CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE—\1) DATE <br /> v 'i6m 9 E D <br /> 29 20161 11 457 <br /> r/ <br /> EbTAL HEALTH <br /> Lit P pA <br /> IT/�SERVICES <br /> r Mill; <br /> RE <br /> Lu <br /> Au o <br /> DEPARTMENT USE ONLY <br /> Application Accepted ate Area ! \ <br /> Employee ID# <br /> Grout Inspe n B Date / SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By A - Date Constructed Well Depth ft <br /> COMMENTS ',.t.�,� Af/"M,' -(.iL /Yb p a^^;...- LMat. `�•:✓1., �.e� S.L/ i/ <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B sh Remitted ( � Service <br /> Re ueslt# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4rd0112 <br />