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' WELUPUMP 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 IV)O t'G.\�/�(\ � L� CITY/ZIP �I� ` C1G�, g�336 D JOB ADDRESS [f, `� ie Svr C. I\ APN l 77��To^�7 M CROSS STREET 0 PARCEL SIZE LAND USE APPLICATION# m OWNER NAME ��7• �CiIY'\�C/.`O� I I�l�l f��// Nff�' PHONE '1 y OWNER ADDRESS '•I�11 (� 1�1�/�^_S��rQ C. V10('1 WA4, CITY/STATE21P� 6 Y C� C 0 q5_334 CONTRACTOR _W'e S 1 `�S'f C- Ort< Y\ PHONE �7511 CONTRACTOR ADDRESS O 1 c t 1�3 CITY/STATE/ZIP � Ccu, Lp� ( I't `/(S 7Q_u SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE Wt---57 F] C-61 ] D-09 11 Other NUMBER 70-7�0 I EXPIRATION DATE k 2Z ZZ GEOGRAPHICAL INFORM ON: Coordinates X Y Township Range Section F NDED USE omestic/Private E Irrigation/Agricultural ri Industrial 1-jWater Quality Monitoring Cl Soil Sampling/Characterization I I Public Water System If different from Owner: Water ystem ame fact Name or Phone Number TYPE OF WORK New Well eplacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) It of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical If of borings ❑ Out-Of-Service Well fJ Out-Of-Service Well Renewal ❑ Cross-Connection Repair I I New Pump F Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION/ Drilling Method NYMud Rotary / ❑ Air Rotary C; Auger ❑ Cable Tool, U Push Point ❑ Other Proposed Well Depth 7-00 ft Excavation Z 94 in diameter ❑ Open Bottom gavel Pack/Gravel Size in diameter U Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameterrin Thickness/Gauge/ASTM Sched�— 'J Steel lastic ❑ Stainless Steel ❑ Other Grout Seal Dept f #t ,1 Neat Cement(94 Ib bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water entoriite(�20%solids) �1 Other Grout Placement Method SYPumped 7 Free Fall F. Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other Concrete Pedestal 7 Dimensions:Width ft Length ft Thick in ❑ Christy Box r Stove Pipe PUMP r, Submersible I; Turbine I 1 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 QUR A V CE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 SIGNED / TITLE DATE IrlILE � i r A U 0 N E � - DEPARTMENT USE ONLY Application Accepted By le* Date-1121 Area Employee ID#Aot_V Grout Inspection By Date,L/� SPEC;;,_ire!; Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By r Date I _ o strIt Well Depth_ ft COMMENTS 6 PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# tb th Q-1`1 I I lu EHD 43.06 WELL/PUMP PERMIT 4130112