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'r <br />rj- <br />4140 <br />t <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />71) r1- 10 ;.3-13 <br />NVK-KtFUNUAt3Lt rtKMll l>ALL LUtf V0J-10V1 FOR INSPECTIONSYIKtS T TEA FROM DATE ISSUED <br />r`/�, I <br />JOB ADDRESS I ANG ►%'t `� L <br />GTY/Z1P <br />CROSS STREET OSPITAL ROAD APN 067-210-01 PARCEL SIZE 576.40LAND USE APPLICATION # <br />OWNER NAME _401�SCHENONEP P- )�— PHONE 209-482-6643 <br />OWNER ADDRESS5256 NORTH CONFER ROAD CITU/STATE/ZIP STOCKTON, CA 95215 <br />CONTRACTOR BRISKI WELL DRILLING CO INC PMONE 209-754-3394 <br />CONTRACTOR ADDRESS PO BX 1539 - 2918 HWY 12 CITY/STATE/ZIP SAN ANDREAS, CA 95249 <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 ., C-61 D-09 Other. <br />PHONE <br />CITY/STATEJZIP <br />NUMBER 237647 EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE .. Domestic/Private xlrrigation/Agricultural _. Industrial _ Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: er SyStern Name o a me or one umber <br />TWE OF WORK XNew Well - Replacement Well Well Alteration/Modification - Other <br />0 <br />_ Monitoring Wells) # of wells _Sal Boring # of borings s) .Geotechnical of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement .. Pum Re air Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary XAir Rotary Auger ! Cable Tool Push Point Other <br />Proposed Well Depth 400 It Excavation 6 in diameter XOpen Bottom i Gravel Pack/Gravel Size 3/8X 1/4 in diameter <br />Conductor Casing 10 in diameter / Conductor Casing Depth 20 - 50 ft <br />Well Casing Diameter 6-5/bin Thickness/Gauge/ASTM Sched .188 XSteel Plastic Stainless Steel .i Other <br />Grout Seal Depth so ft Neat Cement (94 Ib bagV5-10 gal water) X Sand Cement 1n sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method)( Pumped -: Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By riller : Pump Contractor -Other <br />. Concrete Pedestal Dimensions: Width 4 ft Length It Thick in . Christy Box _ Stove Pipe <br />UMP - ubmersible _ Turbine Other HP Pump Set ft Standing Water Level ft, <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. 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 24,yr��HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED G /'7 _ TITLE PRESIDENT DATE 9-11-17 <br />Application Accepted By <br />Grout Inspection By _ <br />Pump Inspection By _ <br />Soil Boring �Inspection By _ <br />COMMENTSyLtiEc'.� <br />DEPARTMENT USE ONLY <br />Date '� i Iy <br />Date C <br />te. <br />_y <br />D <br />0 <br />In <br />In <br />N <br />CEIVEQ <br />'P 13 2011 <br />■■■■■■■■■■■■■■�I ., r <br />■■■■■■■■■■■■■■■Wr <br />SEP 19 <br />0 COU <br />A. Employee I 1 �.. <br />F1 SPECIAL Well Permit <br />...e.i.. n:. <br />4faHADeaft <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />*411 <br />90, <br />gRTM N ry <br />0M- <br />M�/�F 0040 <br />MMUM <br />� <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />*411 <br />90, <br />gRTM N ry <br />