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JfV- 1 > WELUPUMP PERMIT SAN JOAOUIN 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 / 1�L.c� V �a' / CITY/ZIP CROSS STREET / Cl / APN ��J-O�~� PARCEL SIZE LAND USE APP�LIjC!ATION# m Cn OWNER NAME iDP[�/!^�ery%_Q �1�V�d�S PHONE OWNER ADDRESS Y2_r;2 r© /TT /I L�i (�� CITY/STATE/ZIP AW71 el ' .r L CONTRACTOR I L&s"P_ [ L� b`` 1 t �-9 PHONE) 22—f/-9? CONTRACTOR ADDRESS- jig 14 I/ 5e✓x PY-4 CITY/STATE/ZIP M'OlL r4o SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 'l C-61 f I D-09 11 Other NUMBER (,L SkZ Z EXPIRATION DATE.-W/ 7 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE [.l Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Cl Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK XNew Well [1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s)_ #of borings u Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair [1 New Pum 0 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method�X Mud Rotary ❑ Air Rotary (_1, Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Deptlti- i� Excavation in diameter ❑ Open Bottom ,ravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched "2490 ij Steel Plastic C Stainless Steel ❑ Other Grout Seal Depth ft Cl Neat Cement(94 lb bag/5-10 gal water) .Sand Cement /0 r3 sack mix/7 gal water 11 Bentonite(20%solids) �I Other Grout Placement Method X Pumped ❑ Free Fall 1 Other U Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other n Concrete Pedestal %Dimensions:Width ft Length ft Thick in ❑ Christy Box n Stove Pipe PUMP ❑ Submersible[; Turbine I; 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)953-7697 SIGNED L'(_ TITLE p rY L tteV' DATE 3O-"IIP IT I 22L7Z C N M f-H DEPARTMENT USE ONLY (� Application Accepted By Date g D [6 Area Employee ID# j 7kse o�AL�:cS Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By _ Date ❑ WAIVER Received c Soil Borin Inspection By Date Constructed Well Dep ft COMMENTS PE Sc Received Check# Amount Date Permit/ Invoice# Well ID# Codes Info B as Remitted Service Request# �21, -434,1 jQ!' �j' V��O�J�PyQly EHD 43-06 WELL/PUMP PERMIT 4/30/12