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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 _ Ln 77 4 - - m JOB ADDRESS / (i! S "� !� l,L'-V ✓�C Ej CITY/ZIP C d /e, ,�` m D CROSS STREET u-• T j i/ ' AP oel= z G� A_X1F'ARCEL SIZE LAND USE APPLICATION# m OWNER NAME Pa--y VL Veil, P*HONE O/- go y OWNER ADDRESS " ,i-C � r�G CITY/STATE/ZIP( .JS�I—lele-1-1 J CONTRACTOR 1 V l 4 , /�IS b [k I L4R PHONE X2Z ~G/ F.M CONTRACTOR ADDRESS { I L /r 1 L�cr�S �1 CITY/STATE/ZIP / 'y�L d 1-e -t� t SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE V. C-57 rl C-61 i] D-09 11 Other NUMBER667 EXPIRATION DATE 19116 4 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE omestic/Private P Irrigation/Agricultural U Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization t Public Water System If different from Owner: Waler System Name --------Conlact Name or Phone Number TYPE OF WORK XNew Well l l Replacement Well 0 Well Alteration/Modification F1 Other 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U Geotechnical If of borings 0 Out-Of-Service Well Li Out-Of-Service Well Renewal 0 Cross-Connection Repair it New Pump rt Pump Replacement 0 Pump Repair [I Raise Well Casing WELL CONSTRUCTION Drilling Method ) Mud Rotary ❑ Air Rotary 171 Auger U Cable Tool U Push Point ❑ Other Proposed Well Depth�ZL.- -ft Excavation /2— in diameter ❑ Open Bottom ><'Gravel Pack/Gravel Size in diameter U Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter j�z_ in T ickness/Gauge/ASTM Sched.1100ri Steel )141�lastic C Stainless Steel 0 Other Grout Seal Depth_ ll Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water XB entonite(20%solids) [1 Other Grout Placement Method KPumped ':=1 Free Fall ❑ Other C Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Nt�lump Contractor U Other Concrete Pedestal;.-Dimensions:Width It Length It Thick in n Christy Box n Stove Pipe PUMP r- Submersible[! Turbine I; Other HP Pump Set It 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 ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOUR INSPECTIONS- PLEASE CALL(209)953-7697 I/ �/ SIGNED M k.C. 1 v-LtJ TITLE DATEAn' -47 P' E Q 1 9 L y Lf N Tj y DEPARTMENT USE ONLY 'i •' �.G` Application Accepted By/I Date Area V&k Employee ID#�!k► Grout Inspection By _ Date Z k ❑ S?cCl L vvzli r's2i iiiii Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date iConstructed Well Depth �J Z J! ft COMMENTS (E) l.uAIL io f-4,m ,i 1� ;,A 14!�d� -too, i�►Tow/ �.G w.L cS1.t� r ► -v�r� �t� PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 2f, `1 `3C96 3q1 a' 3� -'-1 EHD 43-06 WELL/PUMP PERMIT 4/30/12