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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 ZUy UOJ-/bUf FOR INSPEGIIUNS / IrArinr-0 I TCAri rmuivi Lomir_ raavw J&3 ADDRESS O CITY/ZIP f I CROSS STREET e7AjeAPN 1 u i PARCEL SIZE 65 LAND USE APPLICATION # OWNER NAME PHON OWNER ADDRESS �/ �0)% �V T__j03ie CITY/STATE21P 0,4 �/�/ Q� 6- CONTRACTOR`%�%�+/�//L1�1� ��s PHONE CONTRACTOR ADDRESS �� LG- CITY/STATE/ZIP SUBCONTRACTOR�aGUS d7/ "�LL1// K� PHONE SUBCONTRACTOR ADDRESS LICENSE )OC -57 VC -61 i ] D-09 CITY/ST 17 Other NUMBER V I EXPIRATION DATE 1+ � � 1 - I I GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑ Domestic/Private ;kTrigation/Agricultural ❑ Industrial Ci Water Quality Monitoring IJ Soil Sampling/Characterization Cl Public Water System If different from Owner: ater ystem Name —tact Name or Phone Number TYPE OF WORK A New Well I1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Wells) # of wells 0 Soil Borings) _ # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ew Pump F, Pump Replacement U Pum 0 Geotechnical # of borings ❑ Cross -Connection Repair ❑ Raise Well Casino Drilling Method %Mud Rotary ❑ Air Rotary I_; Auger ❑ Ca le Tool U Push Point ❑ Other Proposed Well Depth_ e5b ft Excavation ZZ in diameter ] Open Bottom Gravel Pack/Gravel Size in diameter 11 Conductor Casing in diameter / Conductor Casing Depth / ft Well Casing Diameter � in Thickness/Gauge/ASTM Sched ZL-Zt,:*�V 0 Steel Plastic 0 Stainless Steel 0 Other Grout Seal Depth s0 ft r Neat Cement (94 Ib bag/5-10 gal water) /-❑ Sand Cement sack mW7 gal water Bentonite (20% solids) [ ) Other Grout Placement Method,ktJhumped 0 Free Fall C Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By 0 Driller Pump Contractor 0 Other Concrete Pedestal -:Dimensions: Width _L/ ft Length = ft Thick ]EZ_t in 0 Christy Box n Stove Pipe PUMP _1)06ubmersibleL) Turbine I; Other HP � Pump Set G 50 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 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. MI / O ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953;7697 SIGNED TITLE DDATE AY Z DEPARTMENT USE ONLY Application Accepted By Date Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By COMMENTS Date Area Employee ID � ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft T m D v v M M PE Codes Sc Info Received BV Check# --Cg's-h Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 3� v3C)5g3o It 2-11-7 UJP0037552- -� 2 EHD 43.06 WELL /PUMP PERMIT 4/30/12