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WELL/PUMP PERMIT P� SAN JOAQUIN 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 LAI r' �.t r' 1Z C (� m JOB ADDRESS �L CITY/Z1 I Ldi�-��6� Z+ J a P rel I 'f J� CROSS STREET S APN ��YQ f -�O 1� PARCEL SIZE r LAND USE APPLICATION# m 1 OWNER NAME 1107 /I PHONE AL-3 - 43;_15 6, y OWNER ADDRESS Z 3 [!I M 10 n CITY/STATE/ZIP 4F�!'c CONTRACTOR MCASe- 1 1 I S1 u I,��t'Il(` PHONE CONTRACTOR ADDRESS - I SP�4 CITY/STATE/ZIj cle�foa rr SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 'X C-57 ) C-61 I) D-09 ii Other NUMBER .��(* EXPIRATION DATE GEOGRAPHICAL NFORMATION: Coordinates X Y Township Range Section INTENDED USE .Domestic/Private 1-1 Irrigation/Agricultural CJ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization 11 Public Water System If different from Owner: Water System Name onlact Name or Phone Number TYPE OF WORK ,New Well eplacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of bdrings L Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair F1 New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method)S,Mud RotarH ❑ Air Rotary n Auger ❑fable Tool U Push Point ❑ Other i Proposed Well Depth ft Excavation in diameter L Open Bottom �Gravel Pack/Gravel Size in diameter L1 Conduct Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel ��Plastic C Stainless Steel ❑ Other Grout Seal Depth ft C'! Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) !l Other Grout Placement Method Pumped J Free Fall n Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By U Driller 5Pump Contractor ❑ Other _ ri Concrete Pedestal -Dimensions:Width ft Length It Thick in D Christy Box 5 Stove Pipe PUMP I", Submersible r; Turbine r; 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 COMPEN JION LAWS. MI MHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 953-7697 SIGNED TITLE LJ d e r DATE �- � C 16 �W ID c a t O Q AL P R1 E o > EP RTMENTUSE 0 LY Application Accepted By Y Date _�77 Area Employee ID#&/, Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Wnith ft COMMENTS T t- / PE Sc Received lqhe # Amount Permit/Codes Ifo B as emitted Date Service Request# Invoice# Well ID# 06575— jr, I I 13S57-75— z0 713 EHD 43-06 4130/12 e,� p2CJ,d� WELL/:UMP PERMIT