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WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE�I �(�,PEERMIT 1t^/��- CALL(2tt09 953-7697 FOR INSPECTIONS t{EXPIRES I YEAR FROM RR'/,O(M\DA/fTE/ISSUED JOB ADDRESS `4'-S• Poe L� - J/I Z CITY/ZIP� I V� r'l] �-t U D CROSS STREET Go�yO S APN�J 1U 3 2 2 C' .t l P�A�RCEELSIZE}!/� LAND USE APPLICATION# ��L.� '� m OWNER NAME A��Isl U 12(11/- {%r�� /Vl A/ 7I hY[-L, R�;' PHONF��r qOI � 1 ) 1�-F'Q. y OWNER ADDRESS(� (-1CLILA yI'�, \ ^�w ' • I n , CITY/STATE21P,�t G( (� C /` CONTRACTOR l� �1/JlI IT, C ,! �-`.j�p t/v�n.-}CNI (w�I I Y V HONE f�� `_ `l .f�Jv� CONTRACTOR ADDRESS LVJ VaVI !T�/`'y (K • CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS /vC^IITY//SSTATE21P LICENSE C-57 L C-61 U D-09 U Other NUMBER 1 `VIWEXPIRATION DATE �© GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USE omestic/Private D Irrigation/Agricultural ❑Industrial D Water Quality Monitoring C Soil Sampling/Characterization U Public Water System If different from Owner. water System Name Contact Name or Phone Number TYPE OF WORK(I.New Well L Replacement Well U Well Alteration/Modification U Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings ❑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 Meth.04E Mud Rotary C Air Rotary C Auger 7 Cable Tool ❑Push Point ❑ Other Proposed Well Depth _ft Excavation 2 in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter ❑Conduc r Casing in diameter / Conductor Casing Depth It Well Casing Diamet I ness/Gauge/ASTM Schad n Steel Il Plastic it Stainless Steel -1Other Grout Seal Dept _ft C Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack miz77 gal water IX,B tonite 2 ° ids) L Other Grout Placemen4Method Pumped ❑Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 7 Driller N!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 ] HEREBY RTIF HAT I HAV •PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAO O N DINANCW STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CUR T A D CT E WIT E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WO OM WS. 24 H G�-N@�ICER IRED FOR INSPECTIQNNSPLEASE ALL(209)9'3-7697 SI ED TITLE /�W 1�`"�Y I/JJ -i' DATE `rV7- VZD!!!!! 201 0 071 �N TqL MENIV VTI DEPARTMENT U E O LY � Application Accepted Data � 7 � Area Employee ID# v J t4V Grout Inspection By Data / ElECIAL Well Permit 1 V Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Dat C nstructed Well Depth ft ` C NLENTS �n PE SC Received Check#/ Amount Date ermiU Invoice# We]I1D# Codes Info B Cash Remitted Service R uest# EHD 43-06 / WELL/PUMP PERMIT 4/30/12