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• WELL/PUMP PERMIT 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 -ti - N I V pa m JOB ADDRESS �/ CITY/ZIP �1 vv �f t D v CROSS STREET APN Q_(� PARCEL SIZE LAND USE APPLICATION# m OWNER NAME HONE2 :q.31— IgVc�,4 q y OWNER ADDRESS CITY/STATE/ZIP IN t /' l6" 1. /✓ � CONTRACTOROt)VM AAA -7 ,lrJPXFLL", ONE :931—32-1 D CONTRACTOR ADDRESS CITY/STATE/ZIP 0q�i � SUBCONTRACTOR PHONE SUBCONT AC R ADDRESS IT.Y/STATE/ZIP LICENSE C-57 11 C-61 rJ D-09 P Other NUMBER V/ EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE omestic/Private F Irrigation/Agricultural [jIndustrial i-, Water Quality Monitoring 1iSoil Sampling/Characterization 11 Public Water System It different from Owner: Water System Name contactName or Phone umber TYPE OF WORK n New Well I I Replacement Well ❑ Well Alteration/Modification F1 Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings D Out-Of-Service Well Out-Of-Service Well Renewal U Cross-Connection Repair t! New Pump 7 Pump Replacement Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION -X Drilling Method U Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool U Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter LI Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel iiPlastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft 1 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water I Bentonite(20%solids) 1 Other Grout Placement Method I1 Pumped _1 Free Fall f� Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 7 Pump Contractor ❑ Other F7 Concrete Pedestal;;Dimensions:Width It Length ft Thick in ❑ Christy Box n Stove Pipe PUMP Submersible; Turbine r; Other HP Pump Set ft Standing Water Level ft I HEREBY CE IFY 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 COMPENION LAWS, M IMUMWHOUR A VA[NCE NO ICE REQUIRED F0Fj INSPE S�- PLEASE CALL(209) 95?-769-7 SIGNED / TITLE l/l. DATE U J VR M N A ' LT D P RVfE EL i I I E ;YMR -i' MENT USE ONLY Application Accepted By Date�� Area Employee ID# Grout Inspection By Date 0 SPECIAL Well Permit Pump Inspection By Date O ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# EHD 43-06 WELL/PUMP PERMIT 4/30/12