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ANOUIf0'a�G� ,�--�—T[� �l!!I'�''' rI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT W ELL/PUM P PERM ST HAZELTON AVENUE-STOCKTON CA 95205-(209)4 -)V r NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 133o 0. tine uy)r� .�1 �z3 ^r JOB ADDRESS CITY/ZIP D -Ito-U G Z ° CROSS STREET CAPN d ARCEL$RE ��)/L(7A�lND USE APPLICATION f� m OWNER NAME `G t Y� G t J iF F' a PHONE/Cd((`-SIE Go"I 3 I N OWNER ADDRESS J I .{-� O p� ,j ITP/gTrA�TE21P �CA4- Y! �j`r" F ' CONTRACTOR LI ,C. L IS�V1 'C ya 1 (J U 1 i PHONE p/yc-,a` ,/'�r,1 r1��[ CONTRACTOR ADDRESS I t • \-1 S� CITY/STAT IP t' -I�T✓, 1"� S,O IV SUBCONTRACTOR \`1 PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP I Y,� LICENSE C-57 L C-61 a D-09 L Other NUMBER 11V.PIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private 7 Irrigation/Agricultural ❑Industrial D Water Quality Monitoring C Soil Sampling/Characterization Lj Public Water System If different from Owner: Water SyStern Nam on ac ame or one um r TYPE OF WORK 3k'New Well i_ Replacement Well a Well Alteration/Modification a Other ❑Monitoring Wells) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of bodngs ❑Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair L New Pump L Pump Replacement a Pump Repair D Raise Well Casing WELL CONSTRUCTION Drilling Method XM Rot C Air Rotary C Auger :1 Cable Tool 11 Push Point ] Other Proposed Well Depth ft Excavation l.2 in diameter a Open Bottom L Gravel Pack/Gravel Size in diameter ❑Conducttor'Casing in diameter / Con ctor C ing Depth ft Well Casing Diameter Y in Thickness/Gauge/ASTM Sche� n Steel )(Plastic F-Stainless Steel i Other Grout Seal Depth M ft C Neat Cement(94/b bag/5-10 gal water) D Sand Cement sack mix/7 gal water Bentonite(20%solids) L Other Grout Placement Method3<Pumped D Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ]Driller C Pump Contractor ] Other D Concrete Pedestal❑Dimensions:Width ft Length ft Thick in D Christy Box ❑Stove Pipe PUMP ❑Submersible]Turbine C Other HP Pump Set ft Standing Water Level ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COU O INANCES, S TE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AN CT WITH TH ALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKE M EN A ON LAW 1 1 2 ED FOR,.,INSP/E�CTI IO�NSS-PLEASE CALL(209)9 3-7697 SIGNED TITLE 1�W�""l I r�r , I�",�' DATE I ENT VED 2017 VI"'N'INEN�ULNTY 16 All T+ TMEN7 " D E,fiA TM ENT 7fS E N Y Application Accepted P Date f! Area Employee ID# Grout Inspeceal PEC L Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring In ection By Date Constructed Well Depth ft COMMENTS PE Sc Received Amount Date Permit/ Invoice# WellID# Codes Into B Cash Remitted Service Request# v 3 S 1N W 4EHD 30/42-06 /�j�a l(� ` i 7 'JL,.0 /�j ��vL�-Vf�H.�" PPERMIT 3�/l .K�