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V +t } WELUPUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 a NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSA�l �AIACITY/ZIP m R O CROSS STREET / /✓L� APND S��J_ `Q'�n PARCEL SIZE.LAND USE APPLICATION# Q/ m OWNER NAME /'�/��Li � � 7 / I�1fr'/�� PHONE OWNER ADDRESS I 3,� �� /UC/ '4�� G� CITY/STATE/ZIP / CONTRACTOR !✓I /�S PHONES ��—��` CONTRACTOR ADDRESS �` ' CITY/STATE21P � •"" 4� ✓ S , t• n SUBCONTRACTOR 4\ �Ll�i�� PHONE SUBCONTRACTOR ADDRESS CITY/STATE//ZIP LICENSE �-57 -61 1 D-09 11 Other NUMBER ��/C7 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE [.j Domestic/Private 11 Irrigation/Agricultural ri Industrial L] Water Quality Monitoring U Soil Sampling/Characterization [1 Public Water System If different from Owner: Water System Name —fact Name or Phone Number TYPE OF WORK n New Well ,VNeplacement Well ❑ Well Alteration/Modification ❑ Other + D Monitoring Well(s) If of wells ❑ Soil Boring(s) #of borings E Geotechnical #of borings ❑ Out-Of-Service Well a Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pum CI Pump Replacement ❑ Pump Repair n Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary ❑ Air Rotary C; Auger L3 Cable Tool U Push Point ❑ Other Proposed Well Depth ZAeV ft Excavation d'-7 in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter L) Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 4;�L.7-a0 U Steee�lastic ❑ Stainless Steel ❑ Other Grout Seal Depth06V— ft 1'; Neat Cement(94 lb bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water ,111dentonite(20%solids) 1 Other Grout Placement Method !.I Pumped _1 Free Fall r? Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ;Vump Contractor ❑ Other ] Concrete Pedestal Dimensions:Widthft Length ft Thick in 7 Christy Box ❑ Stove Pipe PUMP Npubmersible[1 Turbine Other HP '7 _ Pump Set ft Standing Water Level —ft I HEREBY CEIITIFY 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. MW14 ADVANCE NOTICE REQUIRED FORM/SP�EC�TIONS- PLEASE CALL(209)95;11,76 7 SIGNED �''.�` .�Z�/i TITLEDATE r-71a'6 tl AT r' J .j N C U LT D P L I I I I 1 I I EP T M E N T YISE PNLY -f� � Application Accepted By Date � Area Employee yee ID# Grout Inspection By Date p� ❑ SPECIAL Well Permit Pump Inspection By Date,ill �b j� ❑ WAIVER Received Soil Boring Ir*pection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# ko 15 goC) ?,o wF' f)�m I " VqL EHD 43-06 WELL/PUMP PERMIT 4/30/12