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• WELUPUIVIP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-HEFUNDABLE PERMIT JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR e CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS GALL 209 953-7697 FOR INSPECTIONS ME PIHE5 1 YEAR FROM DATE ISSUED Cli ` CITY/ZIP J N 6� "Q/ ' O PARCEL SIZE LAND USE APPLICATION # MMS PHONE CITY/STATE/ZIP 04 P ON C _ • CITY/STATE/ZIP PHONE LICENSE C-57 1 1 C-61 1 D-09 Il Other. CITY/STATE/ZIP NUMBER 3I tr C) LIT EXPIRATION DA 'aEOGRAPHICAL IN ORMATION: Coordinates X Y Township Range Section NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring n Soil Sampling/Characterization Public Water System If different from Owner: ater System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well i Replacement Well ❑ Well Alteration/Modification i Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings i Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal I Cross -Connection Repair ❑ New Pum &Ump Replacement ❑ Pump Repair i Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary i i Air Rotary I Auger ❑ Cable Tool ❑ Push Point a Other Proposed Well Depth It Excavation in diameter n Open Bottom ❑ Gravel Pack/Gravel Size in diameter I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 11Steel 11Plastic Ci Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite (20% solids) ❑ Other Grout Placement Method -1 Pumped ❑ Free Fall ❑ Other Retardant / Accelerator (name) PEDESTAL Installed By Driller I Pump Contractor A Other Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe PUMP , ubmersible Turbine Other HP L 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. 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 LL WORKERS CO,. ENSATION LAWS. MIN M 24 O AD NOTICE REQUIRED FOR INSPEC IONS - PLEASE CALL (209) 953-7 97 SIGNED��~~ TITLE N) DATE Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS 2P.A R T M E N T U E N L Y SC Info Date Check#/ Amount Cash Remitted Date Permit/ Service Request # Date I Well ID# Date Area Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft T D 0 v m N PE Codes SC Info Received B Check#/ Amount Cash Remitted Date Permit/ Service Request # Invoice # Well ID# ,�qp 0 P06-3--7 S°1 EHD 43-06 WELL /PUMP PERMIT 4/30/12