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WELUPUMP PERMIT SAN JOAOUIN 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 JOB ADDRESS 2-1 1c),Z f V^! v, r C mI�� CITY/ZIP /V`e,n4 eel CCS �✓ SS h D O CROSS STREET P r r5cof+ APN 7-06- t Z-0 2—S PARCEL SIZE 1 .(16 LAND USE APPLICATION# m cn OWNER NAME `�(� �! I �j��(� _ PHONE 11921- J(�3c — N OWNER ADDRESS !� } C✓ rl�C� _ OtA,,j) 1l_d _ CITY/STATERIP r •�l/�e.A l rceC 61% c+� ✓5_'6 CONTRACTOR I• W S Q- L�'y IS D C i I Ilk1 L -T;A\ _ 1_ PHONE522 192-iS _ CONTRACTOR ADDRESS ` 1.`� 'J� ` �d .....___ CITY/STATE2IP `/�"tel P U CSI ` SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP__ U LICENSE ')< C-57 r) C-61 I D-09 (I Other NUMBE CJ EXPIRATION DATE I- �« GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township Range__ Section INTENDED USE /',I'-Domestic/Private Cf Irrigation/Agricultural U Industrial 1.i Water Quality Monitoring U Soil Sampling/Characterization I Public Water System I—i'% "' " "\ _ It different from Owner: Water ysterlE a h e Number TYPE OF WORK ",<New Well Replacement Well ❑ Well Alterton/Mo ification CI Other 0 Monitoring Well(s) _ #of wells C1 Soil Borin�(kzll � may ha►� p�reUigI ical of borings ❑ Out-Of-Service Well U Out-Of-V@9tk tu8jRgt@0 *86GPjnPeff#0ir 71 New Pump Pump Replacement 0 Pump Re i II asin WELL CONSTRUCTION Ljy L.IIVII�'' •- Drilling Method )<Mud Rotary f Air Rotary 0 Auger U Cable Tool U Push Point 0 Other It Proposed Well Depth ?�t�L� ft Excavation in diameter _; Open Bottom X Gravel Pack/Gravel Size� in diameter I i Concluctof Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ?-ZX-'3 _ _1 Steel \- lastic L' Stainless Steel CI Other Grout Seal Depth Id 4`3 ft Cl Neat Cement(94 lb bag/5-10 gal water) Cl Sand Cement sack mix/7 gal water )('Bentonite(20%solids) :I Other Grout Placement Method-yPumped :=1 Free Fall , Other 11 Retardant/Accelerator(name) PEDESTAL Installed By �l Driller Pump Contractor CI Other Concrete Pedestal 7 Dimensions:Width ft Length ft Thick in -I Christy Box n Stove Pipe PUMP Submersible! Turbine f 1 Other HP Pump Set ft Standing Water Level _ft i 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. MINIMUM 24 HOUR --ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769-7-7 SIGNED TITLE Drl I P r! DATE / r CA I 1.0 T. e E V ' UN 7' p F L DEPARTMENT USE ONLY ? ---_�l� 1 1_Z Area Em to ee ID# StC/�CG{E,S Application Accepted By Date_�___ p y Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS <S'c/��2at [� o tf�ti�-[�.Fc C �c Fv AA-e- T-r- r" " CS j-7 PE Sc Received (:Phe00#K Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# 3 SI20nof Q C) 43`tr '3 Itis,L 3 '► IZU� `�� EHD 43-06 WELL/PUMP PERMIT 4/30!12