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06- •/ / I WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT SC Info CALL 2U9 953-7691 FOR INSPECTIONS I`Arinw I i tAm MUNI vA i c 170uw Amount Remitted Date Permit/ Service Request # 124 V c. lri� � JOB ADDRESS j S CITY/ZIP CROSS STREET `(' \ �r �' _g APN 2 04 1 PARCEL SIZE LAND USE APPLICATION # 0 2 0 5q eRI G 1661e- PHONE ZO/ i/ k 7 7-70 OWNER NAME OWNER ADDRESS t, CITY/STATE/ZIP f -S�� /'� CONTkACTOR %%�� /N l S � �� }� AryP ) fL1, T A 1 ate+/,d n -fit n PHONE �� /+ % � 57t 7 &-q,( CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS � �� ,0� J LICENSE 14=1-57 'b1 it D-09 ❑ Other CITY/STATE/ZIP z Sc4 /Oil L A? 415-13 y CITYYi/STATE/ZIP_ NUMByER20761 PHONE EXPIRATION DATE f GEOGRAPHICAL INFORM TION: Coordinates X Y Township Range Section INTENDED USE omestic/Private C7 Irrigatlon/Agricultural ❑ Industrial 0 Water Quality Monitoring U Soil Sampling/Characterization [1 Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK ❑ New Well wvReplacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) It of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair n New Pump CI Pump Replacement ❑ Pump ReDair ❑ Raise Well Casino Drilling Method V Mud Rotary ❑ Air Rotary C11 Auger ❑ Cable Tool U Push Point ❑ Other , Proposed Well Depth 3,20 ft Excavation ! iin diameter ❑ Open Bottom 144ravel Pack/Gravel Size E in diameter U Conductor Casing in diameter / Conductor Casing Depth A ft Well Casing Diameter in Thickness/Gauge/ASTM Sched OO U Steel'tic ❑ Stainless Steel ❑ Other Grout Seal Depth ,�/�ft P Neat Cement (94 Ib bag/5-10 gal water) �5and Cement ZOJ� sack mix/7 gal water I Bentonite (20°/ olids) [I Other Grout Placement Method umped ❑ Free Fall f- Other U Retardant / Accelerator (name) (PEDESTAL Installed By ❑ Driller Ump Contractor L Other Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pine PUMP [, Submersible[.; Turbine r 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 WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPE IN WS. M UM 24 URA AN E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE C%Gc�r,P/ DATE `` ZI t-, T m D 0 M a M N nr PAR rMI- (ISE ONLY q Application Accepted By ate Area Employee ID# Grout Inspection B AV Date e 11 SPECIAL Well Permit Pump Inspection B Date ❑ WAIVER Received Soil Boring Inspection By COMMENTS , 4 Itt,S+Wd Date Depth PE Codes SC Info Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 0 2 0 5q EHD 43-06 WELL/PUMP PERMIT 4/30/12