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�niha'l S(W IN( AW 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 /(:.� (� �` `\ 4)e l � 7`? AL/ Public Water System If different from Owner: Water bystem Name 4 '''. CITY/ZIP # of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair U New PumD L Pumo Replacement u Pumo Renair I I Raise Well Casino /APPLICATION CROSS STREET APN - �' PARC�EL,SIZE LAND USE # /��/f a OWNER NAME i"/ C� '1'� / till -7 � VV�� P�F/p A OWNER ADDRESS O ^ O TA IP V {'� C L / J CONTRACTOR C l r /� / 1 �- i.C%�j �J/'�l! / 7�G �!� tF �� r�li/��'c� PHONE CONTRACTOR ADDRESS / Y/ S, J 7 T CITY/STATE21P SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE KC -57 L C-61 Li D-09 L Other PHONE CITY/STATE/ZIP NUMBER , EXPIRATION DATE GEOGRAPHICAL INF RMATION: Coordinates X Y Township Range Section INTENDED USEomestic/Private 7 Irrigation/Agricultural Industrial -] Water Quality Monitoring E Soil Sampling/Characterization Public Water System If different from Owner: Water bystem Name contact Name or one Numter TYPE OF WORK ;K -New Well L Replacement Well Li Well Alteration/Modification Li Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair U New PumD L Pumo Replacement u Pumo Renair I I Raise Well Casino Drilling Method.* Mud Rotary C Air Rotary E Auger 7 Cable Tool ❑ Push Point ❑ Other Proposed Well Depth a > It Excavation 16 in diameter U Open Bottom nU Gravel Pack/Gravel Size in diameter n Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diamet j_ I is s/Gauge/ASTM Sched (Steel n Plastic n Stainles�jSte�jl Other Grout Seal �By meat Cement (94 Ib bag/5-10 gal wafer) and Cement l l/ _ > sack mix/7 gal water (. solids) L Other Grout PlacementPumped ❑ Free Fall L Other U Retardant / Accelerator (name) PEDESTAL Installed By "Driller L Pump Contractor D Other ❑ Concrete Pedestal ❑Dimensions: Width it Length It Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible-] Turbine E Other HP Pump Set ft Standing Water Level ft I HEREBY CEPTIIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COtjM'�IY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT ANP'/ICT E WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS C MpkNS TION LAWS. MI �11IM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 / SIGNED j �� TITLE ! G� �'%%Cl-rL,/ DATE Application Accepted By Grout Inspection By Pump Inspection By rn m a4�5`q V Y d -ENT IV ED 3 0 2017 QAQU!N COUNTY VIRONMENTAL TH DEPARTMENT PA TMENT U E OILY ��jj//jj►► jj ` ate : Area Employee lD#'' �" 1 jA1 ` J Date ❑ PECIAL Well Permit jj®® Date ❑ WAIVER Received EH D 43-06 WELL /PUMP PERMIT 4/30/12