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WELUPUMP PERMIT 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 / Tim J&3 ADDRESS - O CITY/ZIP �15-Z5< mD )e7 APN „-5-) c,� M CROSS STREET PARCEL SIZE USE APPLICATION# tn OWNER NAME PHO� ne:y N/y�� OWNER ADDRESS / ,/��L)//`�"�V��/� CITY/STATE2 — 1PX I/'"' CONTRACTOR ` �//`1`�1� PHONE CONTRACTOR ADDRESS �/ W/L CITY/STATE/ZIP SUBCONTRACTOR /"/1' l�S .CJ/`" � PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE IOC-57 -61 Fl D-09 11 Other NUMBER _ EXPIRATION DATE 1 1• 1 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE 'i Domestic/Private rigation/Agricultural U Industrial G Water Quality Monitoring ❑ Soil Sampling/Characterization I Public Water System If different from Owner: Water System Name tact Name or Phone Number TYPE OF WORK Alew Well 11 Replacement Well ❑ Well Alteration/Modification Cl Other 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings LlGeotechnical #of borings 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair JaMew Pump U Pump Replacement ❑ Pump Repair 0 Raise Well Casing WELL CONSTR6CTION Drilling Method VMud Rotary 0 Air Rotary ❑ Auger Ll Ca le Tool U Push Point ❑ Other Proposed Well Depth415b ft Excavation ZZ in diameter ❑ Open Bottomravel Pack/Gravel Size in diameter Li Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 1?�r in Thickness/Gauge/ASTM Sched 4!!�L Ztt�V U SteelPlastic 0 Stainless Steel ❑ Other Grout Seal Depth_ ft [i Neat Cement(94 lb bag/5-10 gal water) / _0Sand Cement sack mix/7 gal water ,JdAentonite(20%solids) :I Other Grout Placement Method,*"Pumped '_I Free Fall 0 Other [1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 7 Pump Contractor ❑ Other n Concrete Pedestal CDimensions:Width ft Length ft Thick 1Z in ❑ Christy Box P. Stove Pipe PUMP ubmersible[_I Turbine 11 Other HP_�� Pump Set 2 50 ft Standing Water Level ft I HEREBY C RTIFY 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. IVII /O/ AN�fCEE�fNOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953;,769 SIGNED! TITLE DATE Aft-// f - - ZZ O 7 h / o O E LL I ell ri ——i��±—— DEPARTMENT USE ONLY Application Accepted ByAI Date t` l� Area Employee ID Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By + Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth T7/ ft COMMENTS PE SC Received C CheckW Amount Date Permit/ Invoice# Well ID# Codes Info By —Cirlih Remitted Service Request# U�PUU3755"2- EHD 43-06 WELL/PUMP PERMIT 4/30/12