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` WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 . r.. ., NON-REFUNDABLE PERMIT CALL 209 953-769/ FOR INSPECIIUIVS cArmF-.7 r r ct+n rnvwi JOB ADDRESS VIA CITY/ZIP CROSS STREET I APN L/V I 0PARCEL SIZE L� r LAND USE APPLICATION If OWNER NAME PON2^/ OWNER ADDRESS J CITY/STATE/ZIP l CONTRACTOR PHONEZW(//LcJ1 32/F/ 0 CONTRACTOR ADDRESS 20 R) QW CITY/STATE/ZIP ' , / �+"^/ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS C /STATE/ZIP LICENSE )l(C-57'I C-61 l D-09 11 Other NUMBER �S, EXPIRATION DATE GEOGRAPHICAL INFOMATION: Coordinates X Y 1 ownsnlp Mange ,ectlon INTENDED USE Domestic/Private C: Irrigation/Agricultural fJ Industrial Ci Water Quality Monitoring U Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name ------Contact Name or Phone Number TYPE OF WORK F1 New Well [1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) It of wells n Soil Boring(s) # of borings ❑ Geotechnical It of borings ❑ Out-Of-Servic ell U Out -Of -Service Well Renewal ❑ Cross -Connection Repair Fl New Pum Pum Replacement U Pump Repair U 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 ❑ Open Bottom n Gravel Pack/Gravel Size _ in diameter U Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 'j Steel 0 Plastic ❑ Stainless Steel ❑ Other_ Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water I Bentonite (20% solids) ` 1 Other Grout Placement Method U Pumped r 1 Free Fall ❑ Other 11 Retardant / Accelerator (name) PEDESTAL Installed By U Driller 7 Pump Contractor ❑ Other Concrete Pedestal ;Dimensions: Width ft Length ft Thick in i7 Christy Box n Stove Pipe PUMP Submersible F_1 Turbine 1 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. MI IMUM 4 A VANCE NOTICE REQUIRED FOR �INSPECTIONS - PLEASE CALL (209) 95 76 i SIGNED7 TITLEy) O �' 124A DATE =�/ 7 T m D v M m m to U) PE Codes pp� /DEPARTMENT USE ONLY L1 S L Application Accepted By [� .- Date 0� Area Employee ID# Grout Inspection By Well ID# Date ff ❑ SPECIAL Well Permit Pump Inspection By 77 Date 1 ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS L8d�4�)� ZI 4/1 y �D T m D v M m m to U) PE Codes Sc Info Received B hec ash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# y3w ; /SSS 77 /0 l7 W P Co. 376 EHD 4 '-06 WELL /PUMP PERMIT 4/30/12