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r ♦ • WELUPUMP PERMIT SAN JOAOUIN 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 JOB ADDRESS // /� ///I�7�J CITY//,ZIP t/VDI '7 �!/7 D CROSS STREET � �cC r/� V d-3PARCEL SIZE!/ LAND USE'AP(PLI)CA�TI/ON# �J7� �/ / �UL/ PHONt�� !W- ^/ _ m OWNER NAME � OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS �l �� fiC �/�1� /�C! CITY/STATE2IP: //t /% j Z<A � J SUBCONTRACTOR / 5.��-lS D/��L�� J� PHONk�'z� SUBCONTRACTOR ADDRESS CITYY//STCATTEE2/IIP LICENSE C-57 )k-t-61 i) D-09 11 Other NUMBER Cr t7 J /Lr. EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USEDomestic/Private Fi Irrigation/Agricultural N Industrial Ci Water Quality Monitoring LiSoil Sampling/Characterization 1 Public Water System If different from Owner: Water System Name fact-Name or Phone Number TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) It of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ew Pump U Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ,VMudRotaY ❑ Air Rotary Cl Auger LiCable Tool U Push Point ❑ Other Proposed Well Depth Yr L1 ft Excavation in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter Ll Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diame in Thickness/Gauge/ASTM Sched �"t-�i1� u Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Dept ft F' Neat Cement(94 lb bag/5-10 gal water) /❑ Sand Cement sack mix/7 gal water ,fie onite(20%solids) �l Other Grout Placement Method Pumped _l Free Fall F. Other 1.1 Retardant/Accelerator(name) PEDESTAL Installed By Li Driller APump Contractor ❑ Other r, Concrete Pedestal ;=Dimensions:Width ft Length ft Thick in Fl Christy Box n Stove Pipe PUMP Submersible Li Turbine f; Other HP Pump Set__/ ft Standing Water Level G1 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. MI OU CE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)95P-769F SIG ED TITLE G�/'�/`GL DATE-Tj us 414 r. EP RTMENT YSE /ONLY Application Accepted By Date ! Area Employee ID# Grout Inspection By Date 4- ❑ SPECIAL Well Permit Pump Inspection By Dated ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth 2-7!9/ Ift COMMENTS PE Sc Received h Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# v I fu 111SI , Sg AIN,,-, W PoO?�-7(pH2 Ato S I Poo 11to 14 3 EHD 430/2 b43g2- W pX311Pg2 WELL/PUMP PERMIT