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WELUPUMP F RMIT 41 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT ` ^ (;ALL (ZU9) 9b3 r_ -/b9/ FOR IN5PECIIUN5 CAF-Irl0 1 r mown rnvin vm v 7 �,J JOB ADDRESS 1• n 2 11414 u CITY/ZIP CROSS STREET APN SOO 0 V PARCEL SIZE / f � I t LAND USE APPPLICATION #Q V� h qG PHONE fr�� -V � — OWNER NAME //�+ OWNER ADDRESS �P u S CITYISTATE/ZIP �J C * U h � , O CONTRACTOR C/4 w �%� 12,, �. C, PHON 7 6, S- 2 CONTRACTOR ADDRESS Oo ' /1 - / O CITY/STATE/ZIP /Gl C, n:,c . SUBCONTRACTOR _ PHONE SUBCONTRACT�ORR�V 7ADDRESS CITY/STATE/ZIP LICENSE r9 57 r1 C-61 I D-09 11 Other NUMBER 12 is EXPIRATION DATE -V GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE [ omestic/Private ❑ Irrigation/Agricultural ❑ Industrial i7 Water Quality Monitoring ❑ Soil Sampling/Characterization H Public Water System If different from Owner: Water System Name intact Name or Phone Number TYPE OF WORK P--N-e—w Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) __# of borings L, Geotechnical # of borings ❑ Out -Of -Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection Repair [I New Pump r': Pump Replacement ❑ Pump Repair ❑ Raise Well Casino WELL CONSTRUCTION Drilling Method La-Kud Rotary ❑ Air Rotary C; Auger ❑ Cable Tool CI Push Point ❑ Other Proposed Well Depth --?©p ft Excavation - / I in diameter ❑ Open Bottom Leel Pack/Gravel Size in diameter U Conductor asing diameter / Conductor Casing Depth ft Well Casing Dia r int hic�Cness/Gau a/ASTM Sched U Steel rd.Plastic Li Stainless Steel ❑Other Grout Seal epth�/ '� Cl Nea ement (94 Ib bag/5 10 gal water) [I Sand Cement sack mix/7 gal water entonite (20% solids) er Grout Placement Method 'X?umped ❑ Free Fall F Other 11 Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ePump Contractor ❑ Other F, Concrete Pedestal i Dimensions: Width ft Length ft Thick in 7 Christy Box ❑ Stove Pipe PUMP F Submersibles] Turbine I] 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 CO NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS OOMPENSATION LAWS. M IMU�RADVANCE NOTICE REQUIRED FOR INSPECTIONS - PL�SE CALL (209)953-7697 SIGNED TITLE [/ lQi/t t-12 /,ss/` DATE Io , 7/ DEI A R T IMiNT SE ONLY l --1 (0 Application Accepted B Date n Grout Inspection By ate Pump Inspection By `� Date Soil Boring Inspection By Date COMMENTS / m D v v M m V) N Area Employee ID# �""" El SPE AL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Codes SC Info Receivedheck ash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# IRV �7a� I d° ; �; S(L c�� s WVO03u50c9 (0-7 141 EHD 43-06 4/30/12 WELL/PUMP PERMIT