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+, r-V-�-Z- 8 � /f /1) WELUPUMP PERMIT P/ t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (ZU9) 9b3 -/b9/ FOR IN5PEG11UNb r_Arrnw r r =Mn rnvrvl vni JOB ADDRESS CROSS STREET_"✓(/,�/�Y'�[ N PARCEL OWNER NAME C //GL�L •��cir//4��/ CITY/ZIP IZE LAND USE APPLICATION # ��1',r P1zu � �~!'rs"S PHONE OwNFL7 Ann{]FSS ---IrCITY/STATE/ZIP CONTRACTOR --/X CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE W-3-57 1 1 7 D-09 11 Other GEOGRAPHICAL INFORMATION: Coordinates X Y PHONE�I��/��L1�J CITY/STATE/ZIP' PHONE CITY/ST A T E /ZI P NUMBER EXPIRATION DATE Township Range Section INTENDED USE omestic/Private C Irrigation/Agricultural ❑ Industrial G Water Quality Monitoring Cl Soil Sampling/Characterization [l Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK ❑ New Well P Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) If of borings L Geotechnical # of borings ❑ Out -Of -Service Well CJ Out -Of -Service Well Renewal ❑ Cross -Connection Repair P, New Pump )eump Replacement U Pump Repair t7 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger Ll Cable Tool D Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ;7 Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft Neat Cement (94 lb bag/5-f0 gal water) ❑ Sand Cement sack mix/7 gal water !_I Bentonite (20% solids) [ I Other Grout Placement Method _I Pumped ❑ Free Fall 7 Other 11 Retardant / Accelerator (name) PEDESTAL Installed By U Driller XPump Contractor ❑ Other Concrete Pedestal -D' ensions: Width It Length ft Thick in D Christy Box h Stove Pipe PUMP ubmersibleU Turbine I; Other HP L Pump Set a 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 COMPENSA ION LA . MI U NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953 76911 SIGNED TITLE �6�L'/L��- DATE ARTMENT U jON L Application Accepted By Date Grout Inspection By Date Pump Inspection ByDate 2 Soil Boring Inspection By Date COMMENTS Area qq Employee ID# SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft T PE Codes SC Info Received By ec Amount Remitted Date Permit/ Service Request # Invoice # Well ID# Q I , EHD 43-06 WELL /PUMP PERMIT 4/30112