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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 QQ Ln JOB ADDRESS C _ CITY/ZIP / /o rn m 0 CROSS STREET m PARCEL SIZE f LAND USE APPLICATION# A ff ` / nn Cn OWNER NAME ti CA,?) �/ d Y 7— PHONE vi c / OWNER ADDRESS CITY/STATE/ZIP VQ11 CONTRACTOR ! OCi{ 1 �!� PHONE 9��j"1CC �GZZ6S, CONTRACTOR ADDRESS O S L�fiYLf! /S_ t(/`C CITY/STATE/ZIP SI:BCONTRACTOR �/l° PHONE 11(p / SPEICONTRACTOR ADDRESS ` 0 rZ4aU 1124ClCITY/STATE/ZIP 8� Li-ENSE C-57 ❑ C-61 ❑ D-09 r I Other NUMBER / j.L1P / EXPIRATION DATE '4� p i GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE 11 Domestic/Privy I!('1TrRAfiilTl AR(Pli Vdttt ality Monitoring Soil Sampling/Characterization ❑ Public Water Srt . � If different from O er: TTT�a I V 1 4 RvatemMosartAimme a I a Ike Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ FVenTamNhav"xPjf8{oT ion ❑ Other ❑ Monitoring Well(a1heiitrfi� rh�(' #of borings I�eotechnical #of borings ❑ Out-Of-Service W II ��rr��r1l�i 1.,9 -Of ry ell,Renewal ❑ Cross-Connection Repair ❑ New Pum 1 � _ WDAMer� � a i ivision ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method a Mud Rotary ❑ Air Rotary 11%uger i I Cable Tool ❑ Push Point f I Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I I Gravel Pack/Gravel Size in diameter i j Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched CI Steel ❑ Plastic I I Stainless Steel LI Other Grout Seal Depth ft 1114 Neat Cement(94/b bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water s Bentonite(20%solids) LI Other n.v j' "'" Cs+ L.() . -girt Grout Placement Method ❑ Pumped XFree Fall LI Other I I Retardant/Accelerator(name) PEDESTAL Installed By 11 Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP I i Submersibles Turbine ❑ 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS - PLEASE CALL (209) 953-7697 SIGNEDIN ; C, ^�1 — TITLE 1 FV 3-90 ( Ft-�&N IN1Et, DATE�� Tv^��f7J C QAA JO Q 1'H H E AL 3 L IT E VI E EPARTMtN �i U E v dLY Application Accepted Date Area -'l--� Employee ID# cam Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received heck#/ Amount Date Permit/ Invoice# Well ID# Codes Info By s Remitted Service Request# '�37 ISD 5- 3 3 �z3 sem g93 EHD 43-06 WELL/PUMP PERMIT 4/30/12