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_ riiw Scan �Iwir' 0 /r� ` F ✓ 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 ADDRESSI /'Kf r-Il f/�4f � CITYIZIP r,' y �/ 72 CROSS STREET� SPL/ rJw APN 'Z(78'O Y a /'7 PARCEL SQE(�(.�LAND USE APPLICATION If M OWNER NAMEA4. P�HONE 3 OWNER ADDRESS /� - �r, CITY/STATE/ZIP//// • 4 ry146 �/I 7 —47U CONTRACTOR (24hV4 •`I/ 7&f f [ 7 1 /A ra CONTRACTOR ADDRESS co � ie.+ Y CITY/STATE/ZIP rC( C A e " ,C-J ra SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 'Wk-5 LICENSE 7 it C-61 P D-09 C1CI /S Other NUMBER / J —2 1YEXPIRATION DATE-31- 2 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USE omestlGPrivate ❑ Irrigatlon/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization n Public Water System If different from Omer: Water System Name Contact Name or Phone Number TYPE OF WORK "eW Well l7 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) If of borings ❑ Geotechnical If of bodngs ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair n New Pump ❑ Pump Replacement ❑ Pump Repair n Raise Well Casing WELL CONSTRUCTION Drilling Method "ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other Proposed Well Depth c94r. it Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_/�_ in Thlckness/Gauge/ASTM Schad OR 2 1 ❑ Steel Allssfic ❑ Stainless Steel ❑ Other Grout Seal Depth 2,-3e, Cl Neat Cement(94 lb bag/5.10 gal water) ❑ Sand Cement sack mixl7 gal water te(20%solids) !] Other Grout Placement Method "umped D Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 942omp Contractor ❑ Other n Concrete Pedestal cDimensions:Width It Length it Thick in ❑ Christy Box ❑ Stove Pipe PUMP p-19'ubmersible[1 Turbine G Other HP Pump Set It Standing Water Level h 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 AF WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMP SATION LAWS. MINI M 24 VA CE NOTICE REQUIRED FO/R� INSPECTIO/1;�7J� P ASE CALL(209)953-7697 SIGNED TITLEL%IYJd1n& /! DATE J �S O Dt ^tf[ PARTMENT U-� WS t0 N L Y ��,.,�� Application Accepted Er- ��`{/)-y'/IL_,� Date Area �� Employee ID7r/1cYuy�a Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth H COMMENTSL851Z 'I/1lCZ(, gr-jd4/&�. IN PE SC Received eck# Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Request# 4 U ,1 S(�bT1/32 -silo i (o Osq `C t 7I EHE 6306 WELL/PUMP PERMIT