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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AvENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMFr CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1181 "��G =2 rn ra N 2 0 . y Q N <br /> Joe ADDRESS r'CnYIZw s W/*�TVN I 92-L746 m <br /> n <br /> CRO53 STREET A GGE SS 'W�D APN 12-1 -0" -COCQ�__PARCEL SIZE 3.r LANG USE APPLICATION# S <br /> r'NcrPlt L7�tS �9ivD 6G t�117�fc (� L( R ONED 11 17-J14 tsoN ravtaclK <br /> OWNER NAME /�L�r� ,/�_[—J� 7th '7Vj����//�"N ( PHONE gZs ' MIC I>7C/C. <br /> OWNER ADDRESS fig;,��yI,��V��"fi/� �/��T�r� /�B•'r/Vp���VU _•-7CRYI$0TATE/2JP�I�v'e'l�/�/7� � ��r�• j`•�I�/)/ <br /> CONTRACTOR � t�'T,� oPZywiNn�)p�G✓J { PHONE <br /> CONTRACTOR ADDRESS 30190 6W-Vf7l C, -v.—T CR`/l$TATE/7JP 7��r ,A1✓r`�r`� •`��71 <br /> SUBCONTRACTOR PHONE —_ <br /> SUBCONTRACTOR ADDRESS — _ CRYISTATi/ZIP <br /> LICENSE C-57 C-61 D-09 1Other NtarM 6138 114 ExputATKIN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X 3'1'- Township Z N Rani Section ZS- <br /> INTENDED USE Domestic/Pnvale Irrigation/Agriculturet Industrial Water Queity Monitoring /Soil Sampling/Characterization <br /> Public Water System <br /> If different hnm Owner er spienri me nlaa Namea Phone Numbe, <br /> TYPE OF WORK New Well Replacement Well Well Alleration/Modification Other <br /> Monitoring Wells) #of wells Soil Bonng(s) sOl berlry. Geotechnical rN #dbnnng. <br /> Out-Of-Service Well Out-OfServlce Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth/0 -20 It Excavation e in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth h <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft /Beat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall i Other TO 6 M 16 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width ft Length h Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level h <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 /> M� R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9533-A7697 <br /> SIGNED_ _ TITLEIPROJT�" E1VN <br /> G7/ E6lQ DATE 13—3" <br /> •� V � <br /> PAYMENT iJIL 2017 <br /> RECEIVE OMMENTAL HEALTH <br /> RMIT/SErRMES <br /> JDAQUIN CC'" <br /> Ep�(1RONMEh <br /> HST}{DEPART <br /> .117 <br /> E P.ARTMENT UPE CINLY C <br /> Application Accepted By ate j�( 7,; 1-7 Area Employee I <br /> Grout Inspection By Date 1 J ' PECIAL WCII Permit <br /> Pump Inspection By Date ® WAIVER Received <br /> a V 1t/ <br /> o <br /> O� Soil Bodng specUon By � VVDate 2 VU Constructed Well Depth <br /> Tr,S COMMENTS 7•Ji 2ft <br /> V-e Cor �7 <br /> PE SC Received CM Amount mltl Per <br /> ✓t( L� /n� Codes Info Remitted Date Ssfvlee Request/ Invoice A We81DM <br /> 3 <br /> Iran /ee,� /, <br /> (e�X -I(/ l / VJ012~ IG' ` wT�4�.L��JH c�'TL.Ic_-G�� �!�!/I�� I�JIh� WELL MP PERMIT <br /> Lilt gl zo W ejl r%l� 47rgW CST�',C ' lb SuF,�1rrE T��C/'7610 -&W. (6 v <br /> ��7J 7 (lam) fa/,r.✓ Ev /36 �i 6xac•—l�rlb�i/X��; BE<o'), z "lw No 6 /YIi�✓u, s� <br />