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J Z. WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT �%,! -:ALL (ZUU) yb3-/by/ FOH INSPEG I IUNS / �r=Arrnlr0 r%r�r-r�n rnvivi vm I r- �Q�..�� JOB ADDRESS J 7 l! / 1 6 / rU ,, 99 �j CITY/ZIP /�« C+'6",- el/I 9"—;? -3Z CROSS STREET i/y'3 .tel APN U PARCEL SIZE 3, C:' LAND USE APPLICATION # OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADDF SUBCONTRACTOR AjV fvt' PHONE SUBCONTRACTOR ADDRESS LICENSE X C-57 r 1 C-61 it D-09 ❑ Other CITY/STATE/ZIP- NUMBER 7e)� EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE�Q Domestic/Private Irrigation/Agricultural Industrial ,:; Water Quality Monitoring U Soil Sampling/Chars terization I) Public Water System If different from Owner: Water System Name-------- Contact Name or Phone NumWK _- moi/ TYPE OF WORK ❑ New Well )( Replacement Well ❑ Well Alteration/Modification ❑ Other ""I V Well(s) # of wells Soil Boring # of borings ❑ #If rings ❑ Monitoring Well ❑ Boring(s) Geotechnical � ❑ Out -Of -Service Well LI Out -Of -Service Well Renewal � ❑ %? Cross -Connection Repair $ / �Q'' New Pum F' Pum Replacement E,Pum Re air F1 Raise Well Casing�All 41' WELL CONSTRUCTION tj miry, o MENTgL �PATMENr Drilling Method A Mud Rotary Fj Air Rotary F', Auger Ll Cable Tool 11 Push Point ❑ Other Proposed Well Depth_'5W ft Excavation -1 R_�2 in diameter ❑ Open Bottom X Gravel Pack/Gravel SizeTin diameter Ll Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter -g_ in Thickness/Gauge/ASTM Sched p Z / 'i Steel rJ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft Cl Neat Cement (94 lb bag/5-10 gal wafer) 9 Sand Cement /0.3 sack mix/7 gal water !.I Bentonite (20% solids) '.1 Other Grout Placement Method )( Pumped :=1 Free Fall F Other [] Retardant / Accelerator (name) PEDESTAL Installed By K Driller _1 Pump Contractor ❑ Other .Concrete destal -Dimensions: Width � ft Lenqth ft Thick 6, in ❑ Christy Box ❑ Stove Pioe PUMP Submersible I? Turbine I; Other HP % � Pump Set %t�L) ft Standing Water Level /yG- f 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 24 UR ADVANCE NOTICE REQUIRED FOR INSPECT ONS - PLEASE CALL (209),953-7697 SIGNED TITLE a✓�%le' ��"�' % DATE L' 7- 17 X T m D °o m m N DEPARTMENT USE ONLY Application Accepted Date S f Area �� Employee ID# �C r17id Grout Inspec ' n Date ❑ SPECIAL Well Permit Pump Inspection By , Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Codes SC Info Received B _ hec ash Amount Remitted Date PermiU Service Request # Invoice # Well ID# g t R��5 W�oo31�w�5 4-3 gv as a<57, 3 o ..:r S UIILW 003 S PW EHD 43.06 V r WELL /PUMP PERMIT 4/30/12