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V WELL/PUMP PERMIT PX, 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 ADDRESSZ &10 / C 14�� /zip CROSS STREET APN '%1) Ste' 'Z --S 0L �) PARCEL SIZE Iii,44AND USE APPLICATION # OWNER NAME "o' -1 e.", -/4 auddinC iHHONE OWNER ADDRESS `� t�ITY/STATE/ZIPIC CONTRACTOR �G— PHONE CONTRACTOR ADDRESS //J L!' �� ` �j J" CITY/STATE/ZIP ©�`� C� / S ✓�f SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 r ] C-61 i l D-09 ❑ Other NUMBER ✓ EXPIRATION DATE GEOGRAPH!CA1 IWFORMAT!ON' C00rdir-1— Y Y Township Ranoe Section NTENDED USE U Domestic/Private E Irrigation/Agricultural A ndustrial ❑ Water Quality Monitoring U Soil Sampling/Characterization Ll Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK ❑ New Well Ll Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical If of borings ❑ Out -Of -Service Well L1 Out -Of -Service Well Renewal ❑ Cross -Connection Repair n New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method U Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool U Push Point ❑ Other Proposed Well Depth ft Excavation in diameter g Open Bottom ❑ Gravel Pack/Gravel Size in diameter Ll Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ; ] Neat Cement (94 lb bag/5-f0 gal water) ❑ Sand Cement sack mW7 gal water I Bentonite (20% solids) l Other Grout Placement Method ! 1 Pumped -i Free Fall_ , Other U Retardant / Accelerator (name) PEDESTAL Installed By D Driller Pump Contractor Other Concrete Pedestal -Dimensions: Width ft Length ft Thick in ❑ Chtfsty Box n Stove Pipe PUMP I-.Submersible(i Turbine r Other HP=,4=gZ Pump Set ft Standing Water Level 7 v 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 HOUR ADVANCE NOTXE,REQUIRED FOR INSPECTIONS - PLEASE CALL (209 952-76 SIGNED =P_E-P-A-RTMENTUSE ON Y Application Accepted By Date 6 4411Grout Inspection By Date Pump Inspection By Date IV (�/ Soil Boring Inspection By Date COMMENTS � Area Employee ID# ❑ PECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft N D v O m m N PE Codes SC Info Received B Check s Amount Remitted Date Permit/ Service Request # Invoice # Well ID# EHD 43-06 WELL /PUMP PERMIT 4/30/12