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r <br />71) r)- I ;�3-1 i <br />t1'A <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT [:ALL LUy V54-/15VI FOR INSPECTIONS PIKtS 7 TEA FROM DATE ISSUED <br />n/ c 1{ ,y�I 1 <br />13 5L 4 U <br />JOB ADDRESS rLJ I GI �G r Y1 Q �� `CITY/ZIP <br />CROSS STREET OSPITAL ROAD APN 067-210-01 PARCEL SIZE 576.40LAND USE APPLICATION # <br />OWNER NAME �SCHENONE Z_,Zyc_vi?k, PIC_ (Z "��-- PHONE 209-482-6643 <br />OWNER ADDRESSCP256 NORTH CONFER ROAD CITY/STATE/Z1P STOCKTON, CA 95215 <br />CONTRACTOR BRISK[ WELL DRILLING CO INC PHONE 209-754-3394 <br />CONTRACTOR ADDRESS PO BX 1539 - 2918 HWY 12 CITY/STATE/ZIP SAN ANDREAS, CA 95249 <br />TOR ADDRESS <br />XC -57 -i C-61 D-09 Other <br />PHONE <br />CITY/STATEIZIP <br />NUMBER 237647 ExPIRATION DATE 11-30-17 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE - Domestic/Private .x Irrigation/Agricultural Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner water SyStern Name o a me or Phone N.mber <br />TYPE OF WORK X New Well I Replacement Well Well Alteration/Modification a Other <br />Monitoring Well(s) # of wells Soil Boring(s) I <br /># of borings I Geotechnical # of borings <br />Out -Of -Service Well I Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method . Mud Rotary )(Air Rotary . Auger � Cable Tool i Push Point Other <br />Proposed Well Depth 400 ft Excavation 8 in diameter XOpen Bottom Gravel Pack/Gravel Size 3/8X 1/4 in diameter <br />Conductor Casing 10 in diameter / Conductor Casing Depth 20 - 50 g <br />Well Casing Diameter 6-5/$in Thickness/Gauge/ASTM Sched _188 XSteel Plastic - Stainless Steel _ Other <br />Grout Seal Depth 50 It -1 Neat Cement (94 Ib bag/5-10 gal water) X Sand Cement 10 sack rnix/7 gal water <br />I Bentonite (20h solids) _i Other <br />Grout Placement Method)( Pumped _. Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By riller - Pump Contractor , Other <br />i Concrete Pedestal _Dimensions: Width q It Length <br />It Thick in Christy Box Stove Pipe <br />uM ubmersible- Turbine . 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 />MI IMUM 24HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED -A P TITLE PRESIDENT DATE 9-11-17 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS UWtitt!C.1— - <br />DEPARTMENTUSE ONLY <br />//F� <br />Date " 1 1 �� - 13' <br />r Date /c-�9—�) 7 <br />_N <br />D <br />0 <br />Mm <br />N <br />CI <br />"OgQLIN <br />^1 [ H p fpMEM4`1 <br />Area Employee ID# Gv <br />��� <br />SPECIAL Well Permit <br />P WAIVER Received (� / <br />S <br />Fp4AFQ/41 <br />EHD 43-00 WELL /PUMP PERMIT <br />4/30/12 <br />