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f 4 _ . WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL 211.199b3-/bUI FOR INSPECTIUN5 CArlrlr-O r TtAM rrMUFV1 vHIr- 1o0ucu JOB ADDRESS L/ I 716 Hazy 69 ' CITY/ZIP/ a e'kf e4i7 9-,;7;2:3z Invoice # CROSS STREETAT✓d: i;V5 ,2 f U - Z2O - PARCEL SIZE Z V LAND USE APPLICATION # ��B` �]} j�APN S�Cv�7�� �f OWNER NAME G �(•�CC.�/'re4yo- a PHONE / / 7 ZZ (MVILhW /�A%N� 7' � � OWNER ADDRESS / �/L��l �/� CITY/STATE21P f2rTlZaco-W / CONTRACTOR l �1 ��' E/�I1/7L %?CJ PHONE �.j%/ / / 7 CONTRACTOR ADDRESS / �D h Id111f�{� 2t � CITY/STATE/ZIP i&&q 'IS 64 �25— Z SUBCONTRACTOR L1�1� PHONE SUBCONTRACTOR ADDRESS LICENSE AC -57 '] C-61 i) D-09 [1 Other CITY/STATE/ZIP NUMBER 1 (Ol . EXPIRATION DA GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE 'X Domestic/Private F. Irrigation/Agricultural [I Industrial ❑ Water Quality Monitoring ❑ Soil Samplin (I Public Water System If different from Owner: Water System Name-------- Contact Name or Phor TYPE OF WORK C1 New Well )( Replacement Well ❑ Well Alteration/Modification ❑ Other 0 Monitoring Wells) # of wells ❑Soil Borings) # of borings ❑ Out -Of -Service Well f I Out -Of -Service Well Renewal C Geotechnical r-1 Crnss-Cnnnectinn Rannir NA.. ltf rings 2017 New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing QU/ WELL CONSTRUCTIONTy 0 Afb —'IvTY Drilling Method �j Mud Rotary ❑ Air Rotary C Auger Ll Cable Tool 11 Push Point 0 Other �P�TMENr Proposed Well Depth_ ft Excavation f •/ / /, in diameter ❑ Open Bottom X Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter Conductor Casing Depth ft Well Casing Diameter Jo—, in Thickness/Gauge/ASTM Sched:!W#—' 7 / U Steel K Plastic 0 Stainless Steel ❑ Other Grout Seal Depth ft [1 Neat Cement (94 lb bag/5-10 gal water) 9 Sand Cement /a - sack mix/7 gal water I Bentonite (20% solids) � 1 Other Grout Placement Method jK Pumped -i Free Fall ❑ Other [I Retardant / Accelerator (name) PEDESTAL Installed By K Driller Pump Contractor ❑ Other .Concrete Plbdestal Dimensions: Width ft Length ft Thick 6, in ❑ Christy Box n Stove Pipe PUMP Submersible[; Turbine r] Other HP % �/L Pump Set j&) ft Standing Water Level /S�G� it ft r. 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. MINIMU)t 2$,!�OUR ADVANCE NOTICE REQUIRED FOR INSPECT)ONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted - -- Date � I S l Grout Inspec ' n Date Pump Inspection By , Date DATE e' 7- / 7 T Area --? % Employee ID# 1E SC107TV ❑ SPECIAL Well Permit ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS Cf-517<7cam. /ii--uL- 6*7c . PE Codes SC Info Received By hec Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 4 r ��B` t 3l� t �� (� IS 1� S�Cv�7�� W rO0 311btii 4-3 a -v a 5�3 (MVILhW 003 C53T lS EHD 43.06 WELL /PUMP PERMIT 4/30/12