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11214-e-,-1 CA <br />CONTRACTOR i'‘..4-,15reen3r5E-6MPJ DE4 5.315f,k1 GLeL PHON(207) Z <br />CONTRACTOR ADDRESS Pc 134C 504 CITY/STAITJZIP (5't gaiNii Ties-7 2/ <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/Zip <br />UCEN3E 4-C-57 I C-61 ' Other NUMBER 7,113ff EXPIRATION DATE 2r .5t L 2- <br />CITYISTATFJZIP <br />JOB ADDRESS lor33 RO- CfTY/ZIP pt*Al 95c <br />CROSS STREET p4r2a$,—) 1+1.04 APN 9 -1 sZ 9. PARCEL SIZE 41t-1 ( LAND U3E APPLICATION* <br />OWNER NAME IctlatE PHONE <br />OWNER ADDRESS 2.4.*)".4- LiftiNfrhi - <br />DEPARTMENT USE ON .Y ,4& o (tic 71, I t Date I Area Employee IDS <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring insp <br />COMMENTS :11113210CIV 311S WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SOO EAST MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />GEOGRAPHICAL INFORMATION: Coordinates X Township Range Section <br />(INTENDED U3E Datomestic/Privete -; Irrigation/Agricultural Industrial 1 Water Quality Monitoring 1 Soil Sampling/Charagtenzation <br />c---- C Public Water System if different from Owner WOW .,sIern Name f,trOlott NOE.. Of Crow, Nureser <br />TYPE Of WORK New Well Replacement Well <br />' Monitoring Well(s) *of wells <br />r Out-Of-Service Well <br />New Pump , .5's•Pump Replacement <br />Well Alteration/Modification ri Other <br />Bet bOrInno Soil Boring(s) <br />Out-Of-Service Well Renewal T Cross-Connection Repair <br />Pump Repair Raise Well Casing <br />Geotechnical <br /> <br />of toongs <br /> <br />WELL CONSTRUCTION <br />Drilling Method Mud Ro Itjr Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter , Open Bottom Gravel Pack/Gravel Size in diameter <br /> <br />Conductor Casing in diameter / Conductor Casing Depth tt <br /> <br />Well Casing Diameter in Thickness/Gauge/ASTM Soiled Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft - Neat Cement (94 lb bag/5-10 gal water) Sand Cement 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 Driller Pump Contractor ' Other <br />Conerete Pedestal Dimensions Width It Length ft Thick in - Christy Box Stove Pipe <br />HP Pump Set ft Standing Water Level _X__ ft PUMP ubmersibleD Turbine Other <br />I HEREBY RT1FY 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 COMPENSA • LAWS. <br />24 HOUR ADVANCE NOTICErejEOUIRED FOR INSPECTIONS <br />TITLE raw DATE SIGNED -12/e/it <br />uitfee <br />_ <br />PE <br />Codes <br />SC <br />Info <br />ReceivedCtc; <br />By <br />--al? <br />, Sit <br />Amount <br />Remitted Me <br />Permit/ <br />Serrice Request # Invoice ft Well ID,/ I <br />43e1 c-s1) ee 1.9licV 0,53 -1-, i14 51Zoo <br />COD 43.0e <br />&name <br />WELL PEkm: