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WELLIPUMP PERMIT • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT /` `1 ICApLL 209 953-7697 FOR INSPECTIONS yr EXPIRES I_S 1 YEAR FROM DATE ISSUED JOB ADDRESS ;�a �-+' k CrTY/ZIP CROSS STREET APN (_i.�� I[l V �U PARCEL SIZE LAND USE APPLICATION# ' ^ m OWNERNAME Ff,/!\,G,Y1d1pz( HEX,-�,I� PHONE `lr e �(J o OWNER ADDRESS �"`VY�/-�C.I�`- � WW ,,f,n I ( CITY/STATE/ZIP C— (iWV\ L/ '^V��^ !J CONTRACTOR 0��i-(P l�Ct/Y��r S VV`t:/l�tp Do l 41 h PHONE q./k�/(I1��G. '� (a CONTRACTOR ADDRESS II�DI JV I\l U-V\ AV SAT, A CITY/STATE/ZIP M Y Cr 1,V,; D SUBCONTRACTOR N( ' A PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /� � (�1 LICENSE C-57 L C-61 U D-09 U Other NUMBER ``� EXPIRATION DATE l r"'" `' GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ INTENDED USE Domestic/Private 7 Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization U Public Water System If different from Owner. Water uysterri Narre Contact Name or enone NUMber TYPE OF WORK >(New Well L Replacement Well U Well AlterationlModification - U Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings 0 Geotechnical #of bodngs ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair U New Pump L Pump Replacement U Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Method>(Mud Rotary C Air Rotary C Auger Cable Toot ❑Push Point ❑ Other � Proposed Well Depth b0 ft Excavation in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter rl Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameterin Thickness/Gauge/ASTM Sched FI Steel n Plastic rl Stainless Steel -1 Other Grout Seal Depth 1QQ_ft C Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mW7 gal water Bentonite(20%solids) L Other Grout Placement Method O Pumped 0 Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 7 Driller C Pump Contractor 7 Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible]Turbine C Other. HP Pump Set 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 JDAQUIN N RDINANCE STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CAED NT A D C IVE WIT E C LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WM ATION S. 1 IRED FOR INSPECT ONS-PLEASE CALL(209)953-7697 SI TITLE �/N��1 I I VI DATE �VCr% 0 4 2017 011N U V U)N Cp ' N%, out -y AgRTALNT DEPARTMENT USE ONLY I � n Application Accepted Date S � Area Employee ID# f Grout InspectionJA Date Z ❑ SPECIAL Well Permit Pump Inspection By ADate ❑ WAIVER Received Soil Boring InspectionecnB ` By� Date Const r to I Depth ft COM�MENTS,`4�33!tcyc�l — �� lTtCwl�iLj7/ 0 AO PE Sc Received Chec Amount Date Permit/ Invoice# WeIIID# Codes Info B ash Remitted Service Request# 43 2 [ Jv h S 0017 W�003'1v1°I EHD 43-08 WELL/PUMP PERMIT 4/30/12