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• # WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 v lit_l r. 4 VrN Icemen NON-REFUNDABLE P JOB ADDRESS CROSS STREET_ OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADI SUBCONTRACTOR ADDRESS LL 209 9b;3 -[t)9/ FOR INSI'tGIIUNZ, GnFrnw . . �..�.n� - --- CITY/ZI Z -7 e1< e 9 PARCEL SIZE _PAND USE APPLICATION # ---__2lY _ Uc� , '1_T�_ (LICENSE J! C-57 I C-61 it D-09 [7 Other CITY/STATE2IP, CITY/STATE/ZIP ITY/STATE21P NUMBE //// PHONE EXPIRATION DATES LL__, 3EOGRAPHICAL INFO MATION: Coordinates X Y TOWnShlp Hange Section NTENDED USE 'Domestic/Private P Irrigation/Agricultural ❑ Industrial [i Water Quality Monitoring ❑ Soil Sampling/Characterization 1 Public Water System If different from Owner: Water System Name--------- Contact Name or Phone Number TYPE OF WORK ❑ New Well [1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical If of borings ❑ Out -Of -Service it LlOut-Of-Service Well Renewal ❑ Cross -Connection Repair [I New Pum Pum Re lacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ; Auger Ll Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I1 Gravel Pack/Gravel Size in diameter 11 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 'iSteel CI Plastic C Stainless Steel ❑ Other Grout Seal Depth ft [l Neat Cement (94 lb bag/5-f0 gal water) ❑ Sand Cement sack mix/7 gal water J Bentonite (20% solids) :1 Other Grout Placement Method 1.1 Pumped ❑ Free Fall F Other U Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller 7,1 Pump Contractor ❑ Other Concrete Pedestal -'Dimensions: Width ft Length ft Thick in ❑ Christy Box n Stove Pipe PUMP Y11Submersible[...! Turbine 1; Other HP Pump Set It 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 S - PLEASE CALL (21 -� DATE I Dcr A" -TNI ENT USE Of" T Application Accepted By Date Grout Inspection By Date Pump Inspection By ! Date_ Soil Boring Inspection By Date COMMENTS Area 0 1 l `% Employee I D# A ",4/�_ ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Codes Sc Info Received B Che sh Amount Remitted Date Permit/Invoice Service Request # # Well ID# o AST3ZI EHL) 43-06 WELL /PUMP PERMIT 4/30112