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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL ZU',f yD3-/bUt FOR IN5PEGIIUN5 CArfnF-Q 1 TCNn r-nvlvl �ou«. JOB ADDRESS �n o Lk,5C?n LA, CITY/ZIP w. enp � CROSS STREET t_c ds a�F rah2 Gf\1_ a- - APN z..3-18 0 -Qj, PARCEL SIZE LAND USE APPLICATION V Q # OWNER NAME _ 1101`liy4�1 � _ PHONE O) O - L '�1�c 1r� \ tj n4 �r ►,:: fW P—j . rck cy C A q55 y OWNER ADDRESS ' OL)r Yl -- CITY/STATE/ZIP CONTRACTOR �kr-wr\ nati trOS Dt i N CA Co :4-I\C PHONE `5 415 l X85 CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE >:P-57 r7 C-61 [ 1 D-09 [7 Other CITY/STATE/ZIP YYl O(�P S -O r ` Ft Cil 5 7 _ PHONE CITY/STATE/ZIP NUMBER 2.908)? EXPIRATION DATE S`31 -i GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE ❑ Domestic/Private - rrigation/Agricultural ❑ Industrial [_i Water Quality Monitoring U Soil Sampling/Characterization II Public Water System It different from Owner: ater ystem Name ontactName or Phone Number TYPE OF WORK New Well [1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings U Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump F1 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method><fAud Rotary ❑ Air Rotary ❑ Auger U Ca e Tool j?,,LIPu h Point 0 OthertQrvc.rS P. �cs�GtYY Proposed Well Depth 50ft Excavation ��cYi _ a'Ur_ Open Bottom Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth Q ft Well Casing Diameter in Thickness ge/ASTM Sched Steel ❑ Plastic C Stainless Steel ❑ Other Grout Seal Depth A011 Rlat Cement (94 Ib bag/5-10 gal water) ) Sand Cementer .3 sack mix/7 gal water I Bentonite (20% solids) Other 3 Q� X UD ' Vol -\A u r+0 Y-0 a S I �Oex --� �yy�n }� Z:A Grout Placement Method )eumped -I Free Fall f7 Other - _ ❑ Retardant / Acceferator (name) PEDESTAL Installed By ❑ Driller t` Pump Contractor ❑ Other Concrete Pedestal :'Dimensions: Width ft Lenqth ft Thick in ❑ Christv Box P Stove Pioe PUMP F; Submersible(! Turbine 1; Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT 1 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIREM FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED �,'�Ty,- JU LU O. �� ZO ITLE �[ , Y DATE IO J7 "') DEPARTMENT USE ONLY Application Accepted BAAi Date i L) l Area O Ct Employee ID#km ' _ Grout Inspection By Date I t aSt L2- ❑ SPECIAL Well Permit Pump Inspection By _ Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth �(OQ ft COMMENTS f r ")v_ � 7zy A_ r nen -c zc �C �111A �_' Lir a I inA , A-14i0� L tizioc tiwt L im PE Codes PC Infoh Received CheckV.. Amount Remitted Date Permit/ Service Request # Invoice # Well ID# �� o3g asp y 1U 3 WPC) Jq1 EHD 43-06 WELL /PUMP PERMIT 4/30/12 T m D v v M m N