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i v s r Ir INA , WELL/PUMP PERMIT L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 NON-REFUNDABLEPERMIT •�iJ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED En JOB ADDRESS ;J `� I • _ CITY/ZIP I� T o CROSS STREET ' I �i I A'PNMV I ��Oa PARCELSIZE�/_LAND USE APP(L�ICATION# (( m OWNER NAME M I ct nid -1 �D hEK!-_( `Gj k Q-0,1_6P �1 PHONE -1p.Lf I �"I u N OWNER ADDRESS�41(po l p (yM(J.]J,,io� iI' Q A CIN/STATE/ZIP - (� _Ail CONTRACTOR CaS�% l A (Eat A��_ Iyn�/�41 Dirt A I I VL 61 i PHONE..1�_,k^.w9 LP .3J /7�(0 CONTRACTOR ADDRESS 10 O' �J I Y G:1n /'Tv�+ M' CITY/STATE21P�bkt 4&1 '' SUBCONTRACTOR ISI ' A PHONE SUBCONTRACTOR ADDRESS Crrrry//S�TATE/ZIP (� LICENSE C-57 L C-61 U D-09 U Other NUMBER l v 1 EXPIRATION DATE l l u GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ INTENDED USE DomesticlPrivate U Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization U Public Water System If different from Owner. vvateriYMM NBM UontactNameorvrlon. oro r TYPE OF WORK New Well L Replacement Well U Well Alteration/Modification U Other 0 Monitoring Well(s) #of wells D Soil Borings) #of borings ❑Geotechnical #of borings ❑Out-Of-Service Well ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair U New Pump L Pump Replacement U Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Method)(Mud R tary C Air Rotary C Auger�t�-Cable Tool ❑Push Point ❑ Other Proposed Well Depth �� ft Excavation in diameter U Open Bottom u Gravel Pack/Gravel Size in diameter rl Conduc Casing in diameter / Conductor Casing Depth It Well Casing Diameter_Z in Thickness/Gauge/ASTM Sched n Steel n Plastic rl Stainless Steel -1 Other Grout Seal Depth 100 it C Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mixt7 gal water 24 Bentonite(20%solids) L Other Grout Placement Method XPumped ❑Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 7 Driller C Pump Contractor 7 Other ❑Concrete Pedestal❑Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible]Turbine C Other HP Pump Set ft Standing Water Level ft 1 HEREBY CE FY AT I HAVE P EPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN C INANCES, ATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRE AC V WITH CA ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORt(f�/�$ 0 PE S ION MU 4 ED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE.OW oti1 i- ISI 1yl DATE -2—t AqY RFS NFNT �R Cb,Zvp �OqF T_F_T # EPARTMENT USE ONLY Application Accepted By Date 11 a - Areae Employee ID# Grout Inspection By Date 2/ I ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection,By ate Constructed II Depth v ft p�� COMMENTS A� s t j �I !'�AA A L o.. "G PE Sc Receive C Amou t Date Invoice# Well ID# Codes Into B ash Remitted Service R uest# 1tj 4366 Iriu / 397 'f39 I /y _.._ �".4Ci,1 EHD 43-06 WELL/PUMP PERMIT 4130/12 HD 91��I�