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WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERRMIrT� GALL ZUy Ub3-/bUt FOR INSPECTIONS I`Arlrtl`a II TtAM rnvm uAIIt raaucu ReceivedChe B ' AV J i M 4 K+'eC.A 41 �� Z�� JOB ADDRESS �U "i � l ✓A CITY/ZIP 43� CROSS STREET L o it / S �e 4 ✓"e �3 Q APN �G �s6 ~ / 1 PARCEL SIZE Z L/_BAND USE` APPLICATION # OWNER NAME �/rIVC _rS I I^ b6 2, 2_1 WPoo3��3 OWNER ADDRESS 11nnn Z � • l J /�/�PHONEE R1 µ S T 1 H /1) _ CITY/STATE/ZIP r • e? Al TCC -1 . Com'! CONTRACTOR M ctSe 11; S U/` 1 11 1 VK I1^• i PHONE 3 ZZ` 10 7— 0 CONTRACTOR ADDRESS 1[ 9 A l be r S CITY/STATE/ZIP /• Ld11 f d/ CIA _1535 SUBCONTRACTOR NTRACTOR ADDRESS LICENSE -f4 C-57 '1 C-61 F) D-09 11 Other CITY/ST/ATE21P_ NUMBER (0611¢4OZZ PHONE EXPIRATION DATE 9- 3o - r 7 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE -)4. Domestic/Private [I Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization Cl Public Water System 7 If different from Owner: Water System Name contactName or Phone Number TYPE OF WORK ,) New Well Ll Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Wells) # of wells ❑ Soil Boring(s) # or borings J Geotechnical ❑ Out -Of -Service Well IJ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ! New Pump C1 Pump Replacement ❑ Pump Repair ❑ Raise Well Casinq # of borings Drilling Method -(Mud Rotary ❑ Air Rotary F'i Auger ❑ Cable Tool U Push Point ❑ Other Proposed Well Depth ZZ,O ft Excavation - /2—_ in diameter ❑ Open Bottom NGravel Pack/Gravel Size Ofc, in diameter U1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter ,(0 in Thickness/Gauge/ASTM Sched'Zi5n_ U Steel `Plastic C Stainless Steel ❑ Other Grout SeaDepth A$0 ft rl Neat Cement (94 /b bag/5-f0 gal water) ❑ Sand Cement sack m&17 gal water entonite (20% solids) ! I Other Grout Placement Method Yumped i=1 Free Fall r, Other U Retardant / Accelerator (name) (PEDESTAL Installed By ❑ Driller INPump Contractor I]Other "'. Concrete Pedestal i Dimensions: Width ft Lenqth ft Thick in ❑ Christy Box ❑ Stove Pipe r A r PUMP 17 Submersible[ 3 Turbine 1; Other HP 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 ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR ,/-` INSPECTIONS - PLEASE CALL (209) 79531-7697 SIGNED S s':S� I i� TITLE Z)o /' � DATE/ 2-4 7 ;Z Application Accepted By Grout Inspection By Pump Inspection By Soil Boring COMMENTS Date .1217-1 Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth .ri PE Codes Sc Info ReceivedChe B ash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 43� fl 3�7SZ 3l0% 12 2�'if10 Sr,007(P506 WPoo3��3 & 0071o606 EHD 43-06 WELL /PUMP PERMIT 430112