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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 (2U9) 953-11591 FOR INSPECTIONS CArlt'ICJ r T IZAH I-NUIVI vH i v iaaUcv JOB ADDRESS �7' // /L� %L�-----e�`7�/� /`�—J CITY/ZIP Amount Remitted Date 'rt/ d-3PARCEL Invoice # CROSS STREET �q� � L f/� / I SIZE l/ . a LAND USEE�JA�PPPLI)CATTIIOfNIf OWNER NAME G'7 / �UL / PHONIa e/ !!/ f- /�A�Zj� OWNER ADDRESS ' j�/li �� /C.aL� I-+ ��i • /�/ CONTRACTOR 5 C .�—/L ��1 c7 -CITY/STATEIZIP PHONE CONTRACTOR ADDRESS �I !� %�G /' /�-��! CITY/STATE/ZIP : //f /u Z� �4 S �—% ��f l� PHON` SUBCONTRACTOR G�/� SUBCONTRACTOR ADDRESS LICENSE YC -57 ,)1&-61 n D-09 11 Other CITTYY//S'TATE2IP NUMBER `K'Fsk /? EXPIRATION DA GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private E. Irrigation/Agricultural 11 Industrial I] Water Quality Monitoring U Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK F1 New Well Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings E Geotechnical # of borings `❑�,, �O1ut-Of-Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection Repair New Pump L' Pump Replacement ❑ Pump Repair ❑ Raise Well Casino Drilling Method WMud Rota ❑ Air Rotary F, Auger Ll Cable Tool LI Push Point Other Proposed Well Depth Rotary Excavation Z in diameter ❑ Open Bottomravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diame 6 in Thickness/Gauge/ASTM Sched C-L—Z�2i U Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Dept ft Cl Neat Cement (94 Ib bag/5-10 gal water) / ❑ Sand Cement sack mix/7 gal water Ate onite (20% solids) � 1 Other Grout Placement Method XPumped '_] Free Fall F. Other U Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other Concrete Pedestal ;- Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP VSubmersible(I Turbine I ; Other HP Pump Set__j ft Standing Water Level Lr 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 OU CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9 769 SIGNED TITLE C.�/� DATE 0_7_:Y " / '.'pr EP RTMENT SE N L Y Application Accepted By Date rT Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By COMMENTS Date Areaq-,/q.q Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth 2-79' ft PE Codes SC Info Received B Ch ash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# v i I SS `rki W Poo X702 5 M WP00131(045 1��•I'In,II� WELL /PUMP PERMIT 4/30112 43q2,