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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ,,l I^L G( �I/J CITY/ZIP &+1��p -l y U/ L&+11 /� f d CROSS STREET aA�r,jk206L lI k-jO41 APN 16 j i3oO iltiO0 b PARCEL SIZE 2419"I LAND USE APPLICATION# OWNER NAME PHONE OWNER ADDRESS CITY/STATE/ZIP q CONTRACTOR Q rll)!{71 1- /J A, CPHONE (n'l)tCI L''�g�j`-)3 L.1 S CONTRACTOR ADDRESS �l Z� CITY/STATE/ZIP +��1 r L1( [ S SUBCONTRACTOR �ro,'L�i17/1�1� PHONE LZ/i7ot/i) -0- �09 SUBCONTRACTOR ADDRESS l= t7 +�t`yG 6 l /CIT�1Y/STATE/ZIP (ir`�►+ '1 r lit T C/1 -14 P LICENSE AC-57 ❑C-61 ❑D-09 ❑Other NUMBER 6 T 3Y-r74 EXPIRATION DATE 6— ! —t7 3 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings >"Geotechnical #of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump R lacement ❑Pump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary 'Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth /5--5 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter t ' ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water �I ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name *Le P" ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped OL Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑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. 1 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 SIGNED K --�"� TITLE y`f'G�1` (3-t0 IV6 f DATE �'l r 2' n M . a.. eubi T M N AL 41, T 4=ateENT UST�LYYApplication Accepted By 2- G Area Employee ID# " 3/ Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Constructed Well Pepth ft COMMENTS !¢� PE SC Received _ Check#/'" Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# 07d- t5_0 EHD 43-02-006 WELL PUMP PERMIT 1/27/2005