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49 ♦' WELL/PUMP PERMIT i^ / <br />SAN JOAOUW COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East HaaRon Avenue-STOCKTON CA 95205-6232 - (209) 4683420 <br />NUN-KEFUNDABLE PERMIT <br />UALL (LUy) ySJ-/by/ FOR INSPECTIONS rArIKCC1 l TEAR FROM DATE ISSUED <br />Joe ADDRESS <br />, 00 <br />C 167'7-LFM+ u <br />cmRIP Loo/ Y Sri 4D <br />N� <br />CROSS STREET <br />N1\k)- !it <br />f� <br />f/" Z PARCEL S¢E LAND USE APIPU�CATI�ON/# <br />OWNER NAME <br />TAPN <br />cy <br />1oJ�- �A� A) ('D J( /PC¢Q <br />1 <br />PHONE f r <br />OWNER ADDRESS <br />Ny-Nw�S'C9�, -9S'Q <br />q-364g� <br />CITY(STATE/ZIPZ-& c yyo <br />CONTRACTOR <br />/rr303 <br />U <br />U� F,D�-SO�tlS R1MP <br />�p cannye^ <br />SC/e UICE adz ;Q7rJ <br />CONTRACTOR ADDRESS AOo6.2 <br />A125w HOPE <br />�PHONE <br />,PD Cfrr/STATE21P <br />SUBCONTRACTOR <br />PHONE <br />:TOR ADDRESS <br />C-57 i i C-61 i i D-09 i i Omer <br />Clrr/STATE/LP <br />NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFoRMAnoN: Coordinates X Y Township Range Section <br />NTENDED USE pkpomestidPrivate ! ! Inigabon/Agricultural 1.: Industrial ! ! Water Quality Monitoring ! ! Soil Sampling/Characenzation <br />i i Public Water System <br />If different from Owner Water System Nam Cartlad Nam or Phone, Number <br />TYPE OF WORK VNew Well ! i Replacement Well ! i Well Atterabon/Modification ! i Other <br />! i Monitoring Well(s) d of wells i i Soil Boring(s) *of borings i , Geotechnical tl of borings <br />Out -Of -Service Well i i Out -Of -Service Well Renewal i i Cross -Connection Repair <br />WNew Puma i i Puma RRnlar ment ! i Puma Repair i i Raise Wall Cam -'nn <br />Drilling Method i ! Mud Rotary i i Air Rotary i i Auger ! i Cable Tool i ! Push Point i i Other <br />Proposed Well Depth ft Excavation in diameter i i Open Bottom i i Gravel Pack/Gravel Size in diameter <br />i i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thidmess/Gauge/ASTM Sched i i Steel i i Plastic i ! Stainless Steel i i Other <br />Grout Seal Depth ft 1 1 Neat Cement (94 Ib bag/5-10 gal water) ! i Sand Cement sack mix(7 gal water <br />i i Bentonite (20% solids) i i Other <br />Grout Placement Method i ! Pumped i i Free Fall ! - Other i i Retardant / Accelerator (name) <br />PEDESTAL Installed By ! ! Driller i ! Pump Contractor i ! Other <br />! ! Concrete Pedestal Dimensions: Width It Length ft Thick in i ! Christy Box ! ! Stove Pipe <br />--- <br />lam X Submersible ! Turbine ! ! 00ker HP Pump Set 1-0/6 It Standing Water Levelft <br />I HEREBY CERTIFY THAT 1 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 />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump fnspecbon By <br />Soil Boring Inspection By <br />COMMENTS <br />24HOUR/�DVANCE NOTICE REQUIRED FOR INSPECTIONS <br />Q 1'' �� TITLE DATE <br />I� <br />l 7 207 <br />a'inIJEA <br />YMENT <br />ECEIVED <br />L Z 8 2011 <br />DAQUIN COUNTY <br />✓IRONMENTAL <br />fH DEPARTMENT <br />EP RTMENT tISE Q/NLY �/' <br />DateTD <br />Area_ Employee ID7f �-U I <br />Dale SPECIAL Well Permit <br />Date WAIVER Received <br />Date Constructed Well Depth It <br />EHD 43'09 WELL /PUMP PERMfr <br />8101/(18 <br />