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jt�ihal Sian 6� + • WELUPUPAP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 -0 IT NON-REFUNDABLE PERMIT G ALLL(20y)yb J-/b/ FOR INSPEG I IUN5 y lrfa 1 r-Arr- iCAnpr rfVrvl vriic �oovw Date Permit/Invoice Service Request # # Well ID# �y �J (egoLco°0 ►l 7"7J JOB ADDRESS E / 2 �1 �tiS� ✓l , \G _ CITY/ZIP CROSS STREET 4( %i�j� APN oZ,'22i ® Yd 1,:!V PARCEL SIZE AND USE APPLICATION #�7 OWNER NAME ' 1/ It • , PHONE l OWNER ADDRESS - �' u + L CITYISTATE/ZIP / le-? �C-1 -i9 CONTRACTOR /7�/�14 .1 S PHONE J �+ n A �/Kt� /t CONTRACTOR ADDRESS on J . . t� CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE tVC-57 C-61 D-09 rl Other NUMBER �'.�/ 7% EXPIRATION DATE J - -% GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section NTENDED USE iAvtTo—mestic/Private C7 Irrigation/Agricultural ❑ Industrial r_i Water Quality Monitoring U Soil Sampling/Characterization Cl Public Water System _ If different from Owner: Water System Name contact Name or Phone Number TYPE OF WORK Ifs-ffe-w Well Il Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells C Soil Boring(s) # of borings ❑ Geotechnical If of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair I I New Pump n Pump Replacement ❑ Pump Repair F Raise Well Casing WELL CONSTRUCTION Drilling Method P IGTud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other rt Proposed Well Depth Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter � in T ' ss/Gauge/ASTM Sched 54 .� / j Steel L�stic ❑ Stainless Steel ❑ Other Grout Seal Depth �l`7 ft '_ Neat Cement (94 Ib bag/5-10 gat water) ❑ Sand Cement sack mW7 gal water "entonite (20% solids '. l Other Grout Placement Method gimped :_] Free Fall L Other U Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller imp Contractor ❑ Other Concrete Pedestal ; Dimensions: Width ft Length ft Thick in ❑ Christy Box r, Stove Pipe PUMP tXubmersiblerl Turbine r ; Other HP Pump Set ft Standing Water Level -= -ft HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN OUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENTND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS OMPENSATION LAWS. M NIM R VANC OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE('" 4 `` >�S• DATE DEPARTMENT USE ONLY Application Accepted Date Grout Inspection By Date Pump Inspection By Date Soil Boring InspectionBy AMENTS I A-A1,t, IAA bn(e T Area Employee I D# I u'J ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well D a -t ft PE Codes SC Info Receiveda B Cash Amo nt Remitted Date Permit/Invoice Service Request # # Well ID# (egoLco°0 ►l 7"7J V 10003b3 zoo c)(.0 :HD 43-06 WELL/PUMP PERMIT 4!3T12