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WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 W,q,✓kON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED � (J" " JOB ADDRESS lr � i, �� ^J L�1^I �V�—, _ CITYRIP_�� rw� f'D 1 O IID y CROSS STREET „ U),- APN 50'_ C/ PARCEL SIZES.a 3 LAND USE APPLICATION# m Wo l(1 N OWNER NAME -�{''' � it '1 '�l' '��' C �l //.�,� _ PHONE U!1� �/Vf Wo OWNER ADDRESS 1 ��+� ' `� CITY/STATE/ZIP r"/1 �0—t CONTRACTOR JV r'i ' 1�) 1 I�'V_\ADf'_ PHONE( r �7- ";Ll CONTRACTOR ADDRESS _ ` . `fir" , �j _� _.. CITY/STATE/ZIPi S r AoA p ^.J/SUBCONTRACTOR . /J` _ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE f C-57 1 C-61 i i D-09 [1 Other NUMBER ! l L EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township _ Range— Section___ INTENDED USE ,.4 Domestic/Private GC Irrigation/Agricultural U Industrial i Water Quality Monitoring L Soil Sampling/Characterization 1 1 Public Water System If different from Owner: Water System Name contact Name or Phone Num e1; TYPE OF WORK y"New Well /-Replacement Well ❑ Well Alteration/Modification ❑ Other �J ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical--�T— ❑ Out-Of-Service Well U Out-Of-Service Well Renewal LI Cross-Connection Repair `-'t"I 14 2016 ❑ New Pum _- Pump Replacement ❑ Pump Repair 1-1 Raise Well Casing WELL CONSTRUCTION �NVf!-d COVN��' Drilling Methodx-Mud Rotary [jAirRotary F, Auger 11 Cable Tool U Push Point F1 Other HtALTH CPnQT �- Proposed Well Depth •�3 -Z` -@-7 kkcavation i �`�`i in diameter Open Bottom /Gravel Pack/Gravel Size_� in diameter LI Conductor Casing IIYY in diameter / Conductor Casing Depth ft Well Casing Diameter r in Thickness/Gauge/ASTM Sched y� U Steel /Plastic ❑ Stainless Steel ❑ Other_ Grout Seal Depth ( i Neat Cement(94 Ib bag/5 f0 gal water) ;? Sand Cement I('' �rjlw.� sack mix/7 gal water I Bentonite(20%solid 1 Other LPr .P_.i-s Grout Placement Method /'Pumped ':1 Free Fall C Other i Retardant/Accelerator(name) PEDESTAL Installed By 11 Driller /Pump Contractor L! Other Concrete Pedestal ;Dimensions:Width ft Length ft Thick in -1 Christy Box F- Stove Pipe PUMP Submersible!I Turbine 11 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 CALIFO NIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATIAWS. MINIM 24 OUR A A E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED -- TITLE ��.yw�42- DATE ) o-� s o S Wy (� C_ 2( s z S ` " 1,7 C_ �s S 7 71 _ �b t o'I S 120 b G t�5 S Ef^i 4- 0A 5 S z 1g� s t�1S C_ �- - Zu� S I _ 233 F�[ 1—i t L4L C- D PARTMENT USE ONLY Application Accepted RV Date(0 Area �P Employee ID#S OS Grout Inspection Date O D. SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Soring Inspection By Date Constructed Well Depth ft COMMENTSEXIS�_!All::1-� 0 S lr= �L/fZ�J rA1 ;-OU - PE Ste. Received Check#1 Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# / °", (WOO(BD I(a EHD 43-06 WELL/PUMP PERMIT 4/30/12