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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 488.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 963-7697 FOR INSPECTIONS tAVIKhb T YEAR FROM DATE ISSUE <br />JOB ADDRESS '1 K <br />trop/() FRE Igo OT ST cmmp�QS�kTO C K T o N �g52-IS <br />N <br />CRO13 STREET . 0 AVC APN 14 333 a 2.q PARCEL SIZE y. 1 t- USE APPLICATION 0 1�-� /& <br />OWNER NAME B l L 1. Mkkh I AILA A D PHONE <br />OWNER AOORE4Q <br />SS 10 7% t4b TN f GN�►�Y 11 CITYISTATEZI ST0(-KT0NZGF\(15211 <br />CONTRACTOR 1ARTRI5C.-P6 ENhfNEERING L.AWl"itToR"ES Plow 816'3"1$-b700 <br />CONTRACTORADDRE1&3-b01bCj.LLLT PNVE CITY/STATI:IZIP SItcRA�tENTa/Cfl�g581f <br />SUBCONTRACTOR V Ks 1T oAsT ExrwR,AT�� N PHO.& 2-67-795-7S`41 <br />SUBCONTRACTOR ADDRESS �'. AVAX' /33 CITY/STATE/LP ES cA t o N / C. A <br />LICENSE xC-57 - C-61 D-091. Other NUMBER pLL 761 E%PIRAnoNDATE 01/31A0.2 -7L <br />GEOGRAPHICAL INFORMATION: Coordnatei X b3g7 f) 4 1r !-1 Y Lj L*b.OJLi' Township !" Range C0 E SKIIGD <br />INTENDED USE 0 Domestic/Pdvale C Ingalon/Agdwltural C Indus Vial _� Water Quality Mcnilodng X Soil Samping/Characterizetlon <br />❑ Public WaterSystem <br />Il dlh,.M Yam OwrNr: W.W pem oma M <br />TYPE OF WORK n New Well Li Replacomenl Wall Well AlleratiordMoWtication ^ Other <br />I Monitoring Wells) A of wets Soil Borings) s of bonngs 9 Geotechnical Z a o" <br />o "'a <br />i7 Out -Of -Service Wel _ Out-Ol Service Well Renewal I Cross -Connection Repair <br />New Porn Pumo Realacemeni Pump Repair - Raise Wel Casing <br />Drilling Method Mud Rolary Air Rotary k Auger Cade Tool Push Pohl Other <br />Proposed Wall Depth GO A Excavation I in rbamoler Open Bonom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth 11 <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel I " Plastic C Stainless Steel = Other <br />Grout Seal Depth �`� It )( Neat Cement (94 Ib baVS-10 gal water) [. Said Cement sack mrx77 gal water <br />Bonlorvle (20% solids) I Olher <br />Grout Placement Method K Pulped 1 Free Fall ! Other _ Retardant / Accelerator inane) <br />PEDESTAL Installed By - Driller 1) Pump Contractor J Other <br />7 Concrete Pedestal I-DLnenslonc Width R Length R Thick In Christy Box G Stove Pipe <br />Eni MP :J SubmersibleC Turbine ❑ Other HP Pump Sel R Stancong Water Level R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAOUIN 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM <br />/ 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �l�'^'1PL TITLE ENC/N6EICIN4& MANAGER DATE l m/1"I f 2411 <br />T? DEPARTMENT USE ONLY <br />Application Accepted By L'Z L � Dale % `a d �w Mae a Employee IDf <br />Grout Inspection By Dole U SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS -from <br />Date -�, D WAIVER Received <br />Dale J��L Constructed Well Depth <br />gY1�ENT <br />=CEIVED <br />127 2021 <br />QUIN COUNTY <br />OEPART/r ENT <br />PE <br />Codes <br />SC Receivedock#/ <br />Into 8 <br />Amount Data <br />Cash Rom itted <br />or Invoice Y Well IDM <br />ServiceReOuest0 <br />LI3� <br />NSd <br />�F,o Ip. .Z--Service <br />00'-12 <br />r/rn 41 oe <br />U]W 17 <br />/3S,,l 3 <br />WELL HUMP PERMn <br />1-3-� 7 �6ze--�-7 <br />