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' ., WELUPUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N JOB ADDRESS _ I _ CITY/ZIPC ��J�/f O CROSS STREET'CL" At t014 APN �.�¢_ �� PARCEL SIZE LAND USE APPLICATION#_ m OWNER NAME �[ !G< V� __ PHONE ?�` _.. OWNER ADDRESS _7 ��(:' �t f v 7�F,L4 CITY/STATE/ZIPS�ivt�i� C_�'r�^ J / CONTRACTOR G L�I(Lr,S� rX l If,lilt _ PHONE CONTRACTOR ADDRESS I I / /J /ve�/� •z� CITY/STATERy/�� IP � ,,(� �1 _ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP y LICENSE C-57 I C-61 1 D-09 [1 Other NUMBER�fi 6'7 EXPIRATION DATF2�C U GEOGRAPHICAL INFORMATION: Coordinates X Y Township RangeSection INTENDED USE Domestic/Private C Irrigation/Agricultural ❑ Industrial Ll Water Quality Monitoring ❑ Soil Sampling/Characterization I l Public Water System If different from Owner: Water System Name factName or Phone umber TYPE OF WORK )(New Well 11 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings r Geotechnical #of borings 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump r Pump Replacement 0 Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method XMud Rotary L Air Rotary C Auger ❑ Cable Tool LI Push Point 0 Other Proposed Well Depth vZ& ft Excavation /;—I _ in diameter Open Bottom 1-1 Gravel Pack/Gravel Size-19 in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter-40-- in Thickness/Gauge/ASTM Sched .2.Oe— _l Steel ,A�Plastic 12, Stainless Steel 0 Other Grout Seal Depth 100 ft r Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water J4entonite(20%solids) [1 Other Grout Placement Method _ Pumped i Free Fail r Other Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller jPump Contractor 0 Other Concrete Pedestal ;-'Dimensions:Width ft Length ft Thick in 0 Christy Box -1 Stove Pipe PUMP I Submersible[ Turbine I; 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 JOAQUI^I COIINTY 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 IIFUM 24 HOURRAADYANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 /- SIGNED_ L TITLE ClJa�" DATE n. t' 'L i , ra,- 1- OP �I I IE DEPARTMENT USE ONLY Application Accepted B Date Z Area Employee ID# Grout Inspection By A Dater, ❑ SPECIAL Well Permit :JSI t Pump Inspection By Date " ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth -ft 1 C MMENTS PE Sc Received Chec Amount Permit/ U Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# r - EHD 43-06 WELL/PUMP PERMIT 4/30/12