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T� F WELUPUMP PERMIT XJ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 `\\JY NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS '`��,,`�^{ CITY/ZIP D y LV-�� o CROSS STREET APN�oq' PARCEL SIZELAND USE (L/I'CATILO.N[,#^�2 c OWNER NAME PHONE 20 • Ly✓• �U-b�f N OWNER ADDRESS ( Y1� CI /STATEYZIP CONTRACTOR lksi l �T 1.��► �IY�.V� ` 1/�/`{ �� `�rV NE ,^'V^ 77�� / CONTRACTOR ADDRESS Vv�. ) �t-e AITY/STATE21P ! 1. SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/S+TA-TE/Z�IIP� G� l `` LICENSE C-57 L C$1 U D-09 Li Other NUMBER CIC (`r EXPIRATION DATE ` L-lJ� GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Sectionit _ INTENDED USE -DOmestic/Private Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Character'Ization U Public Water System If different from Owner. Water SyStern Name on act Name or From NUMb.r TYPE OF WORK ew Well L Replacement Well U Well Alteration/Modification - U Other ❑MonitoringWell(s) #ofwells ❑SoilBoring(s) #of borings ❑Geotechnical #of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair U New Pump L Pump Replacement U Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Method)`L Mud Rotary C Air Rotary C Auge 7 Cable Tool D Push Point ❑ Other Proposed Well Depth?::�M ft Excavation -a_ in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter FConduc r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter In ess/Gauge/ASTM Sched n Steel D Plastic rl Stainless Steel -1 Other Grout Seal Depth C Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ,?.Bentonite(20%solids) L Other Grout Placement Method Pumped ❑Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 7 Driller C Pump Contractor D Other ❑Concrete Pedestal❑Dimensions:Width ft Length It Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible?Turbine C 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 N ORDINANCES STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT A D C IVE WITH E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WO M E SATION S. I H A QUIRED FOR IN�S�P�E�CTIOINNSS�-PLEASE CALL(209)953-7697 SI TITLED�f 0 - y S 2®j? / it 7-6Cod R Nn. [J l PA TMENT UAE 014LY Application Accepted 8y Date Area Employee ID#,4� Grout Inspection By t Date ❑ SPecIAL Well Permit Pump Inspection By Date ❑ WAIVER ReCelveJl Soil Boring I pection By Date Constructed Well De 3 ft COMMENTSZ-0 'FIE SC Received Check# Amount Date Permit/ Invoice# WeIIID# Codes Info B Remitted Service R uest# 19-7 Lao- b Z t1 EHD 43-05 n WELL/PUMP PERMIT 4/30112 V f /4 /A/C 1 . ,/�A �� O / / _ I A `-C.