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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 so JOB ADDRESS �l V `� / ' ry CITY/ZIP TV /r D L� � 1 �0m CROSS STREET �3M611 !� c�l� APN PARCEL SIZE LAND USE APPLICATION# m � .boy -q� B�Sa y OWNER NAME I O('D/-R " !� rllvr ��(� PHONE C? OWNER ADDRESS �Y/ f /►� 1 r 1 l CITY/STATE/ZIP��TR C L/ .(� 6-r CONTRACTOR 1 Z �,�,� wr �� PHONE Oc I -i -' _ cr/ CONTRACTOR ADDRESS O Jd� �� ! �> 0 CITY/STATE/ZIP �„C, • n/ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS in LICENSE )CC-57 I I C-61 i 1 D-09 [1 Other NUMBER /Q_3 G 30 EXPIRATION DATE -7 f a GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE U Domestic/Private /It Irrigation/Agricultural ❑ Industrial L; Water Quality Monitoring U Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name contact ame or Phone umber TYPE OF WORK X'New Well Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells LlSoil Boring(s) #of borings L Geotechnical of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair n New Pum O Pump Replacement ❑ Pump Repair P Raise Well Casing r WELL CONSTRUCTION Drilling Method AMud Rotary ❑ Air Rotary Cl Augerj` U Cable Tool CI Push Point ❑ Other Proposed Well Depth ;990—ft Excavation !.2 in diameter Ir Open Bottom XGravel Pack/Gravel Size �� °in diameter Ll Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched�� r_) Steel ]tf Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth .%© ft [i Neat Cement(94 lb bag/5-f0 gal water) /❑� Sand Cement sack mix/7 gal water >c$entonite(20%solids) �I Other Grout Placement Method (I Pumped ❑ Free Fall ❑ Other C' Retardant/Accelerator(name) JPEDESTAL Installed By ❑ Driller ,' Pump Contractor ❑ Other I Concrete Pedestal;=Dimensions:Width ft Length ft Thick in ❑ Christy Box n Stove Pipe I ELI—M, Submersible I! Turbine r; Other HP Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT 1 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 COMPEN ION LAWS. nM3W4 HOUR ADV E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 953-7697 SIGNED TITLE 5'- s / - / OwN DATE �g^ Mo �� I f AN JO Q AN C r-14vilu M N AL rr- EPRTMENT U E NLY An Application Accepted By Date Area Employee ID#, Grout Inspection By _ `I Date `` ❑ SPECIAL Well Permit Pump Inspection By _ _? Date V t7' ❑ WAIVER ReceiveA r Soil Boring Inspection y *Date Co structed Welt�Depth ft COMMENTS C G PE SC R ceived Check! Amount Permit/Codes Info B ash Remitted Date Service Request# Invoice# Well ID# 41- � 1 EHD 43-06 WELL/PUMP PERMIT 4/30/12