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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 JOB ADDRESS �� .r-� CITY/ZIP CROSS STREET �Q � L AP/NDK 0A� � v PARCEL SIZE I LAND USE APPLILI�CAATTION# —7 //� m OWNER NAME IVY 1' l v �J� PHONE /�V�/r�J� //�— LC.� N OWNER ADDRESS We��1 I�Z�/ /Gf!' CITY/STATE21l�T(,�lie 7..OA --A `7 S01 Z CONTRACTOR .3I/YI�,,s�^ ( ,,IG� 1IIe/ ,��// PHONEZt;lt77/Z'27,�7 CONTRACTOR ADDRESS ( / SI S/�ID�/'�Y 1941 - CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STAATE21P LICENSE 6 C-57 I] C-61 ❑ D-09 ❑ Other NUMBER IMWEXPIRATION DATEzv GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ INTENDED USE fVomestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Omer: Water System Name ------C—Ont—acams or Phone Number TYPE OF WORK )(New Well )(Replacement Well 0 Well Alteration/Modification ❑ Other 0 Monitoring Weli(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 Replacement 0 Pump Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method KMud Rotary�❑ Air Rotary ❑ Auger 0 Cable Tool LI Push Point ❑ Other Proposed Well Depth 2(co it Excavation � in diameter ❑ Open Bottom XGravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter/k in Thickness/Gauge/ASTM Schad 515&< 7/ ❑ Steel 'Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 40 n Neat Cement(94 lb bagl5-10 gal water) A Sand Cement &7-3r sack mix/7 gal water ❑ Bentonfte(20%solids) [I Other Grout Placement Method Pumped 0 Free Fall n Other I] Retardant/Accelerator(name) PEDESTAL Installed Byfiller 0 Pump Contractor ❑ Other n, Concrete P destal ['Dimensions:Width ft Length it Thick in ❑ Christy Box 0 Stove Pipe PUMP V Submersible(i Turbine f Other HP Z Pump Set ft Standing Water Level /20 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, MINIM OUR ADVANA�TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953--7,697 r/ SIGNED TITLE �!/�!� 'e'�//�'�' DATE Nib I IM T DE ART Date U Y Application Accepted By Date Area I Employee ID# �'� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By � W a�"Date p� Constructed Well Depth ft . LS� �� COMMENTS I — A - TddAM6 r= PE SC Received Amount Date Permit Invoice# Well ID# Codes Info B — Cash Remitted Service Request# Sa .43d,'%d a "b(D &(40701 `1 n s1'0o 20 13 EHD 43-06 WELL/PUMP PERMIT AnNt4