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WELUPUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT JOB ADDRESS _- CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR LICENSE ADDRESS 57 ') C-61 GALL (ZUVUPJ- /bJ/ FUN IN,I'tl;l IVIVb GAr Inw 1 1 c_ n I D-09 n Other /V 1[I it, CITY/ZIP �t 1P I r I I yV 6 .7 o ?c! y ` PARCEL SIZE `f LAND USE APPLIC//A��TION # NUMBER CITY/STATE/ZIP HONE CA CITY/STATE/ZIP t JA ," ! I _L7Z_ 11-4" LV PHONE COY/STATE/ZIP. r V _ EXPIRATION DATE 3EOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section NTENDED USE Domestic/Private C7 Irrigation/Agricultural ❑ Industrial C; Water Quality Monitoring ❑ Soil Sampling/Characterization [ I Public Water System If different from Owner: Water System Name ontact ame or one umber TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical n Out -Of -Service Well rl nllt-Of-SArviCA WAIT RAnA.wAl r1 (rr)AR-Cnnner:tion RAnnir # of borings ❑ New Pump C' Pump Replacement Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method a Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 1-1 Gravel Pack/Gravel Size in diameter LI Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 'J Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft Cl Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mbd7 gal water 1 Bentonite (20% solids) I Other Grout Placement Method ..1 Pumped Ll Free Fall C Other F Retardant / Accelerator (name) PEDESTAL Installed By r-) Driller Pump Contractor ❑ Other Concrete Pedestal ;-Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe Ai PUMP Submersible(1 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. SIGNED l ,C�I/A�lf'a 4'(,1 AUR Nr�.f'/CE NOTICE REQUIRED FQI`, I SP TIONS -PLEASE CALL (20�%9�5�-76 / r� TITLEA�// A DATE 1 / C Area ` Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft T PE Codes DEPARTMENT USE ONLY Application Accepted By Date Grout Inspection By Date Pump Inspection By Date 110Z - Soil Boring Inspection By Date COMMENTS C Area ` Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft T PE Codes SC Info Received B C s Amount Remitted Date Permit/ Service Request # Invoice # Well ID# EHD 43-06 WELL /PUMP PERMIT 4130/12