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L <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS 3655 E.Farmington Road CITYIZIP Stockton.95215 m <br /> D <br /> 0 <br /> CROSS STREET Stagecoach Road APN 17314003 PARCEL SIZE 1.42 Acres LAND USE APPLICATION# <br /> Na, t q I +t ( N <br /> OWNER NAME 14,x) 4�\C�� rt-L^KQ�'V� �.1�,.�`,i.r.'J:%"�1�L�L �-L.C_...- �-P+NON (�, I f)-�'7�"1�'•.I /h <br /> 'OWNER ADDRESS r2- u t. CITYISTATEIZIPF <br /> CONTRACTOR PHONEYS <br /> CONTRACTOR ADDRESS 2nn "�'"'rx=aEBorf$ead c CITY/STATE/ZIP SW406RGAJ1a2V- <br /> SUBCONTRACTOR VSW Drilling PHONE 209-369-9600 <br /> ONTRACTOR ADDRESS 3806 Duck Creek Dnve CITY/STATEIZIP Stockton,CA 95215 <br /> LICENSE El C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 4130/2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agnculturat Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> PubliPublic Water System _ <br /> It <br /> c <br /> from Owner Wafer System Nam Contact Name or PhoneNumber <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other or A. <br /> C # <br /> ❑Monitoring Wells) #of wells ❑Soil Boringof borings s) �Geotechnical 4 <br /> W I <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION �l <br /> Drilling Method []Mud Rotary Air Rotary [Z]Auger Cable Tool Push Point Other r04 I <br /> Proposed Well Depth 5-25 ft Excavation 4.5 in diameter Open Bottom Gravel Pack/Gravel Size H�"Ot" iii <br /> Conductor Casing in diameter I Conductor Casing Depth ft cPgR7MEN <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other I <br /> Grout Seal Depth ft Q Neat Cement(94 Ib begl5-10 gal water) Sand Cement Sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method❑Pumped [7]Free Fail []Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> • Concrete Pedestal 'Dimensions:Width ft Length ft Thick in ChristyBox . Stovepipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level <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 MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> t <br /> SIGNED TITLE Project Geologist DATE 3-8-2017 <br /> J'- <br /> I <br /> OB-2 <br /> O P-1 I <br /> OB_1 B-3 �PP-3 <br /> j <br /> 2? <br /> j�fDEPARTMENT <br /> USE ONLY <br /> Application Accepted By - ' Date ' - Area -- Employee ID#J�ft) <br /> Grout Inspection By Date SPECIAL Well Permit <br /> • Pump Inspection By Date WAIVER Received — <br /> Soil Boring Inspection By } Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Receiver Check#/ Amount Permit/ <br /> Date Invoice# WeIIiD# <br /> Codes Info By Cash Remitted Service Request# <br /> WELL iPUMP PERMIT <br />