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WELUPUNIP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 -7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 2A] 44 F y y^�^ � J� to • JOB ADDRESS/},� t, - Rd �7 CITYY/ZIIP/I �/'�/ ml �/ J3 D CROSS STREET eO.OI V IfL.l/)r'!J \ APP)N Z�� IInn-' - PARCEL SQE70j' AND USE APPLICATION If m OWNER NAME ��_ 1�I 1-ol �mL1,s /PrSu C—��1�1}P}U S 'I?Aa�.C1._'I.��P�E, 2c�'-/�e�-D�-ZS N OWNER ADDRESS 3t34D E. paver 10d I-a11 �IV��."cITY/STATE/ZIP ETAicYI( L -T k( 2n CONTRACTOR II PHONE 2-na}� -C;(4>c/14? CONTRACTOR ADDRESS I CITY/STATE0Pw/✓��NE`�U's/ /L_.f I ?U 3 710 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -57 I7 C-61 n D-09 171 Other NUMBER 22M3 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ INTENDED USE ➢_(Domestic/Pdvate n Irrigation/Agricultural o Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization n Public Water System It different from Owner. Water System Name Contact Name or Frone Nummor TYPE OF WORK =3VNew Well Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Wells) A of wells ❑ Soil Boring(s) a of bodngs ❑ Geotechnical x of borings D Out-0f-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair F1 New Pump ❑ Pump Replacement D Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method,KMud Rotary n Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other Proposed Well Depth-2m. ft Excavation .�2 In diameter D Open Bottom XGravel Pack/Gravel Size _^!J in diameter LI Conductor Casing• in diameter / Conductor Casing Depth _it n�f�� . Well Casing Diamet in Ickness/Gauge/ASTM SchadR 12 2Jo ❑ Steel APlastic C Stainless Steel ❑ Other Grout Seal De ;1 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water entonite 20 ,solids) ❑ Other Grout Placement Pumped ❑ Free Fall n Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other Concrete Pedestal(Dimensions:Width ft Length ft Thick in n Christy Box n Stove Pipe PUMP C. Submersible❑ Turbine I; 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 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. MINIMUM 24 HOUR ADVANCE NOTIC9Ey/lREQU R INSPECTIONS-PLEASE CALL(209))95U3-7697 SIGNED ` y TITLE S V• 1'• DATE J -9—1-7 Py 7 21 Ap M DE ARTMENT USE ONLY Application Accepted By T _ to Areae Employee IDAIUV, Grout Inspection By i 'c Date 7 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Cons rutted Well Depth ft COM TS 7 2 � G PE SC Received Amount Date Permit/ Invoice A Well IDA Codes Info B Cash Remitted Service Request A I 3 I.du 7S2 pb77yk A3 EHD 4306 WELL/PUMP PERMIT 4/30/12