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WELUPUMP PERMIT t SAN JOAQUIN 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 c �_, JOB ADDRESS � v, U/^Y 1e CITYRIP p/r'AI a CROSS STREET /'I'V APN al 1—�1 �U0 �Q, p ARCEL SIZE/ ,LAND USE/1A{P�P APPLICATION(#,}(.,�'� 7 ( �j / M OWNER NAME {�1 4 �+V �C 1 Vr 24 ` 1 y OWNER ADDRESS V ya GITY/STMTE/ZIIP �/� L ' -f ODwsl C . 3W CONTRACTOR f� W1 L �� ` (�V� N�E p !q t -A� ]� CONTRACTOR ADDRESS V O S` r va viR v J -i CITY/STATE/ZIP SUBCONTRACTORT' PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 L C-61 U D-09 U Other NUMBER/' ` EXPIRATION DATE V GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USEDomestic/Private D IrrigationtAgricultural ❑Industrial ❑Water Quality Monitoring C Soil Sampling/Characterization U Public Water System If different from Owner. Water tiysteM NaMe Contact Name or en.n.NUMb.r TYPE OF WORK>(New Well L Replacement Well U Well Alteration/Modification - U Other ❑Monitoring Well(s) #ofwells ❑Soil Borings) #ofborings D Geotechnical #ofbodngs ❑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>�Mudof f-�C Air Rotary C Auger 7 Cable Tool ❑Push Point ❑ Other Proposed Well Depth V ft Excavation—L-L in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter rl Condu or Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched FI Steel Fl Plastic ❑Stainless Steel -1 Other Grout Seal a th 1 C 1> ft C Neat Cement(94 Ib bao-10 gal water) ❑Sand Cement sack mW7 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 7 Other ❑Concrete Pedestal DDimensions:Width It Length ft Thick in D Christy Box D 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 JOAQUI OU ORDINAN S, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRE TAN CTIVE WI TH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL K R C P NSATI0 AW IN CE UIRED FOrR�INSPECpTII�O SI--PL� E CALL(209)95 - 697 TITLE�1�A�LWI 7 111 1111 1 1✓Y �� DATE 1 T VIED 2017 COUNTY ENTAL RTMENT ARTMENT U E qNLY Application Accepted Gd Date Area EmployeeID#� Grout Inspection Bgkf�, Date ❑ PECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS r 771, / PE Sc Received Check#/ Amount Date Permit/Info Invoice# Well ID# -• Codes B Cash Remitted Service Request# 0 1 G� IM12 Wroo-7a 5 CPO EHD 43-06 WELL/PUMP PERMIT 4130112