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WELUPUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH OF PAR TMENT 1668 EAST HAZELTON AVENUE- SSTOCKTON CA 95206 - (209) 468.3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS -- EXPIRES 1 YEAR FROM DATE ISSUED -1„L C •E>>.• JOB ADDRESS _ [_ � _... -s�. �-_ __..-__..._...-_ __... C"/ZIP .. �✓_-„>-G -1._ °'�- _/'� '� ..A..PN U.y..�_1�ARCEL SIXF ___-LANO USE APPLICATIONU OwNF.n NAME Pl10NCJ.. A ,fes' OWNER AnonEss CONTRACTOR.J�!{.H,,isrur✓7.-..L�.S'...__.if`.'.��XL�%yP.__._..__-.. ._._:_._.._..�-_.-.. ., PHONE „!.•r'L=!...r........_-._. CONTRACTOR ADDRESS_,..f_�..��'.�`'�'��._.._.�..__.__._..__._._._...._..__..._._._._ CITY/STATEfLIP,_.J_`,i;:_}i �,.;§,,•�.(_._,_.._..._� SUBCONTRACTOR _.__-_-__ PHONE AUDRESS CrrY/STATEfbP LICENSE 1Z C-57 •i C-61 '1 0-09 Ofher,-,_! _ _._._.... NUMBER M��:(�?��.,,,.:. EXPIRATION DATe_✓A-'��.�� GEOGRAPHICAL INFORMATION; Coordinates x_....._.�..._..__�___.-_.. Y ------ __-..... .......... ... .._..... _.... Township _...... ... Range._..__..__ Section..__.___. INTENOED USE omesticiPrivate 'i litigation/Agricultural (J Industrial ;,i Water Quality Mondonng C: Soil Sampling/Characterization Public Water System .__ _,_ ,--.._,__. 16flo it from Owns . _-_.__._ Waler3ysterli Namo - .__-----____ _ i or f m rin or Piwne Homier TYPE F WORK New Well o Replacement Weil a Well Alteratlon/Modification fi Other Monitoring Well(s) ..... _ . a of wells : i Soil Boring(s) ” x. -'U. (� Geotechnical Out -Of -Service Well a Out -Of -Service Well Renewal [; Cross -Connection Repair New Pumn t i Pumo Reolacement ! Pumn Rebair ❑ Raise Well Casino Drilling Method )Mud Rotary/t C) Air Rotary Auger Cable Tool , Push Point I I Other_ Proposed Well Depth 4,? Eznavatinn _ t., �.__ . in diameter _Open Eottnm >,,(Gravol Pack/Gravel Size.._.____ in diameter [' Conductor Casing in diameter / Conductor Casing Depth __... ..... __----_-. ft Well Casing Diameter P.._ in,-TLllickness/Gauge/ASTM Schad ZjOn ... ': Steel <Plastic p Stainless Steel [1 Grout Seal Depth ZA r Noat Cement (94 Ib bagl5-10 gaffwater) Sand Cement __-_sack mix/7 gal water X"Ientonite (20 solids) : i Other Grout Placement MethodXPUmped Free Fall :..Other -._. ;:Retardant/Acceleralor(name) j PEq installed By L: Driller Pump Contractor U Other - Concrete Pedestal Dimensions: Width It Lenrgth _ tl ''hirk ,_ __ in ;'i Christy Sox Ci 9to" Pt e _.- .._ __. -_____ v., -._a PSubmersible`., Turbine I Other HP Pum Set ft Blandin Water tevol _ r 1t I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 f r n �c �f "y 7 1Cr SIGNEb _._ .__f-.�=ytrf�x.c�i-1P''i _...._- _.__.__.. TITLE -I), II DATE..?`.. a✓ IN IN I I Amount Remiited ----- - -- Permit/ Dale Service Request N -- invoice N Well ION �� tR3` 5 �a� ; ■■■■■■■■ ■■■� ■■ "rlM41 ■ NNS ■ r■�1■■� — ■N ■iii;Mr. ■ M. ■■i■i�■I ■ ■ H !�' ■t 'ro 197, My■■ IP ■■■ 0 ■ iii■ ■ ■■■■■NO ploomm■■ice ■19FLrklw •/ I" s �� ■w � ■■■■■■ ■■■■ ■ ■ A DEPARTMENT USE ONLY Application Accepted By rT ,� -. Date _-�L.°1 .�.. ._ Area_. +; r$�'j:_ Employee IDp,A j y� 1 Grout InSD0001`1 By .__ I T .1 .. �_ .--- - Da'e ..__a_1 Z j Cl .t Id�iG i aitittf Pump laspectiun By __-,- Data ._T ._ I'! WAIVER Received Sal Boring Inspection By _ __... Date— -_.f._._. _- Constructed Well Depth .._3 Z'S ._..._ tt COMMENTS PE Sc Received Checktlf Coder Into 8 Cash Amount Remiited ----- - -- Permit/ Dale Service Request N -- invoice N Well ION �� tR3` 5 �a� ; --- ��i? 1 I \- S , — EHD 43.06 WELL,PLIMP PERMIT 4r,RV l2