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T .gin;Wal Ra IU1(-7 M " A t WELUPUMP PERMIT 101 JOAQUIN 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 /� CITY/ZIP -SWT" _y a CROSS STREET W Df 2}I V APN 212_ jr)D�I PARCEL SIZE LAND USE APPLICATION# Q� m OWNER NAME �(J Q. QI��Pl 1 �f PHONE 20 (_0235—[ OWNER ADDRESS }_1 $�1� 5 /CLC n CITY/STATE21Pl_��i 1 A /�'�[�^ p CONTRACTOR I IU IIII/ FSI U, IM �Y�tQ`��1 i I� PHONE 209^J�'J /�O S/ _ r- CONTRACTOR ADDRESS q U U U i2 CITY/STATE21P_ S� I ICA 9,3'55(o v, SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE kC-57 r) C-61 i 7 D-09 Cl Other NUMBER_ v v EXPIRATION DATE (' GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE XDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization _ [l Public Water System If different from Owner: Water System Name contact Name or Phone Number TYPE OF WORK XNew Well 1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal U Cross-Connection Repair I 1 New Pump 11 Pump Replacement ❑ Pump Repair 11 Raise Well Casing WELL CONSTRUCTION Drilling Method XMud Rotary ❑ Air Rotary , Auger ❑ Cable Tool L Push Point ❑ Other Proposed Well Depth �2_� ft Excavation in diameter '] Open Bottom Gravel Pack/Gravel Size_ In diameter Li Conductor Casing in diameter / Conductor Casing Depth ___ft PXk Well Casing Diameter 9-- in Thickness/Gauge/ASTM Schad X2(2 U Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 100 -ft [l Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack MW7 gal water XBentonite(20%solids) :1 Other Grout Placement Method XPumped �1 Free Fall r, Other L-i Retardant/Accelerator(name) PEDESTAL Installed By 1-1 Driller >CPump Contractor U Other Concrete Pedestal :Dimensions:Width ft Length ft Thick in Cl Christy Box ❑ Stove Pipe PUMP F; Submersible[! Turbine rl Other HP Pump Set ft Standing Water Level It 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. INIM M 24 H� R ADVy,4NC NOTIC RM IRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 SIGNED _ TITLEDATE &4/ P1 I'l Q T til Nry "� TM DEPARTMENT USE ONLY Application Accepted By Date Area Employee ID# �c) Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date El WAIVER Received Soil Boring Inspection By _ Date Constructed Well Depth ft CO MENTS 1 1 PE Sc Received Checkf/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# �-�•-t� T t 7 EHD 43-06 WELL/PUMP PERMIT 4130/12