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WELUPUMP PERMIT SAN JOAQUIN COa'JTY 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 � r _ DJOB ADDRESS I"` N CROSS STREET APN — PARCEL SIZELAND USECAPPLICATIO®N# �/— m OWNER NAME1-50 PHONE -Joe OWNER ADDRESS PC7Y/STATE/ZIP �7&k4w, �// Lov, I444CONTRACTOR � bN qPHONE CONTRACTOR ADDRESS ' L Acv-jr Od Jr CITY/STATE/ZIP / 'r Od"Aj ——or SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 r C-61 1 D-09 [1 Other NUMBER" J� �Z EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township Range Section INTENDED USE U Domestic/Private Irrigation/Agricultural 0 Industrial I_; Water Quality Monitoring U Soil Sampling/Characterization I Public Water System If different from Owner: Water System Name ontactName or Phone Number TYPE OF WORK New Well Replacement Well ❑ Well Alteration/Modification C] Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U, Geotechnical #of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair R New Pump [ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method U Mud Rotary ❑ Air Rotary C Auger U Cable Tool U Push Point ❑ Other Proposed Well Depth.-10 It Excavation in diameter :-] Open Bottom ><Gravel Pack/Gravel Size in diameter U ConducjpjCasing in diameter / Conductor Casing Depth ft Well Casing Diameter(tr_ in Thickness/Gauge/ASTM Sched'/� "J Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth_ft 1-j Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water Bentonite(20%solids) U Other Grout Placement Method X Pumped ;-1 Free Fall r,, Other 11 Retardant/Accelerator(name) PEDESTAL Installed By r.1 Driller Pump Contractor ❑ Other Concrete Pedestal i s Dimensions:Width It Length ft Thick in 0 Christy Box h Stove Pipe PUMP [' Submersible[; 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 COMPENSATION LAWS. ' 1J MINIMUM 24 HOUR 9 DVANCE NOTICE REQUIRED FOR t INSPECTIONS-PLEASE CALL(209)953-77697 I{ SIGNED 1 L V l �� TITLE 1);^f Il�j� DATE//--2?—/1b All 1 J q F Erd 9 V I"-I I I R M D PARTMENT USEONLY i Application Accepted By Date Area Employee ID# Grout Inspection a — Date " Ll,�&7 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date—.... ConstructedGeNth _ft COMMENTSA54t�I✓L?� .i PE Sc Received a Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# 010 1� l W PU031�5 3� S EHD 43.06 WELL/PUMP PERMIT 4/30/12