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WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE STOCKTON CA 95205 (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED _ N V- Com CITY/ZIP_� l JOB ADDRESS l` D CROSS STREET " i y APN ✓ PARCEL SIZE LAND USE APPLICATION# m Cn I N OWNER NAME PHONE �C � -. OWNER ADDRESS V]� Lr �1�1 I l J![�� CC CITY/STATE/ZIPI , L��l -` � l CONTRACTOR I��1 / 7/ ✓/ CN��S LOX 4 /Com\ L �'L� �PPHHONE /�/� CONTRACTOR ADDRESS W— 'lf i / `�i.//� 01 �d, CITY/STATE/ZIP-L/ ( k—hn t-/"1 SUBCONTRACTOR A __ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 C-61 I D-09 11 Other NUMBER_ EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section _ INTENDED USE Li Domestic/Private C Irrigation/Agricultural U Industrial ,:i Water Quality Monitoring U Soil Sampling/Characterization I Public Water System If different from Owner: Water System Name tact game or Phone Number TYPE OF WORK n New Well [I Replacement Well ❑ Well Alteration/Modification D Other U Monitoring Well(s) #of wells ❑ Soil Boring(s) If of borings L Geotechnical If of borings Out-Of-Service Well LI Out-Of-Service Well Renewal ❑ Cross-Connection Repair !1 New Pump - Pump Replacement ❑ Pump Repair n Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger Ll Cable Tool ❑ Push Point Ll Other Proposed Well Depth_ ft Excavation in diameter ; Open Bottom 1-1 Gravel Pack/Gravel Size in diameter Ll Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel 11 Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth__ _ ft I,-] Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water J Bentonite(20%solids) :l Other Grout Placement Method i I Pumped Free Fall Other Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Pump Contractor Other Concrete Pedestal Dimensions:Width ft Length ft Thick in F Christy Box n Stove Pipe PUMP Submersible[1 Turbine G Other HP Pump Set ft Standing Water Level ft 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. I MUM 24\HOURADVANCENOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)9 3-76P7 SIGNED / A104 _._ TITLEO&V/1 DATE A Z Cr �' W Q A. a. 0 Q J Z DEPARTMENT USE ONLY `, ,/ Application Accepted B�`tiytti> Dat��7/ _ Area.. Employee ID#��l-1 V Grout Inspection By _ Date��-777�� ❑ SPECIAL Well Permit Pump Inspection By Date E WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS It7) �� C\ ZU �� spa. �v?;��v��a� � ©L2GILG�\ \ ---- PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# EHD 43-06 WELL/PUMP PERMIT 4/30/12