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t WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL 209 (;ALL 9b3-1bV1 FOR INSPECTIONS GArimr-a lr TrAh rNUIVI U141c/waVcv JOB ADDRESS �_`� IPGL e— CITYR^^IP 7� C'4 75 �� / CROSS STREET 1 �`///`v�c� �� APN 20 L, )00 PARCEL SIZE `- y USE APPLICATION # l , I � h, (LLA,ND OWNER NAME ` ,v r� YHON0/��7A3�f�� OWNER ADDRESS I"/ 3 4- t r' ides'. t- K -Le 1-I &p CITY/STATE2IP h //7✓e/�!'�L 1, C"� % `7 .3 �1 7 CONTRACTOR ` / / r PHONE 77L 2_75-7 CONTRACTOR ADDRESS Cs� `!�/'e�LlZ G�/� CITY/STATE/ZIP /�,�l �s ngY SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STAT'E/ZIIPP Received By LICENSE ZC-57 I C-61 I D-09 [I Other NUMBER �� i0/ s e EXPIRATION DATE Permit/ Service Re uest # Invoice # Well ID# 43� V GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section NTENDED USE /A Domestic/Private C- Irrigation/Agricultural U Industrial Li Water Quality Monitoring U Soil Sampling/Characterization I Public Water System If different from Owner: Water System Name------- (7o n -tact Name or Phone um er TYPE OF WORK ❑ New Well a Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings L� Geotechnical If of borings ❑ Out -Of -Service Well [J Out -Of -Service Well Renewal ❑ Cross -Connection Repair New Pum r! Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCtION Drilling Method Ll Mud Rotary [i Air Rotary C; Auger ❑ Cable Tool D Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom F! Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched fj Steel ❑ Plastic C Stainless Steel ❑ Other Grout Seal Depth ft [' Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water i Bentonite (20% solids) ;j Other Grout Placement Method U Pumped ❑ Free Fall ❑ Other a Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller >e Pump Contractor ❑ Other Concrete Pedestal i _ Dimensions: Widths %ft Length ' z _ ft Thick _� , in [l Christy Box ❑ Stove Pipe PUMP Submersible C! Turbine I ; Other HP_ Pump Set f �� ft Standing Water Level %L� % ft I HEREBY CER IFY 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 COMPENSATIO AWS. MI M UR ADV OTICE REQUIRED FOR INSPECTION PLEASE CALL (209) 953-7697 SIGNED G TITLE/4�G�C�� DATE _- ENV11RUrg1V . - - ENT HEPLTNpEPARTM DEPARTMENT USE ONLY ?vC�� Application Accepted By � ,�— ;:aye 1U_ � Grout InspFction By Date Pump Inspection By Date 1i Soil Boring Inspection By Date COMMENTS Area S/ Employee ID# A h h1j' ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Codes Sc Info Received By Amount Remitted Date Permit/ Service Re uest # Invoice # Well ID# 43� V vs U 4 41 EHD/ /M /. �7—J r ) WELL (PUMP PERMIT 4/30/1212 �J ,� / ` l v v m m in t/1