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. WELL/PUMP PERMIT SAN JOAOUIN 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 � CIT1PTWo ( yacS `/ JOB ADDRESS 7 m D n v CROSS STREET /�i' '_l� APN �60 -_0 PARCEL SIZE I!V LAND USE APPLICATION# m I' -�09 -9 fs - 83Sa y OWNER NAME � � �D/-�^o ! ��(��/'Y PHONE ,A OWNER ADDRESS CITY/STATE/ZIP j? jA C Lt CONTRACTOR /re, P/ V.- CA-PIPHONE Oy I -OU,f f _ cr/ C CONTRACTOR ADDRESSt QS+A y w t ( (� / Iro CITY/STATE2IP T4(,4 C(/ V ' SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE2IP Q LICENSE `)CC-57 I C-61 1 D-09 [1 Other NUMBER d EXPIRATION DATE I ( lJ GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE U Domestic/Private / Irrigation/Agricultural ❑ Industrial I: Water Quality Monitoring U Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK XNew Well Replacement Well ❑ Well Alteration/Modification ❑ Other LJ Monitoring Well(s) #of wells ❑ Soil Boring(s) of borings E Geotechnical a of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair 11 New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method A Mud Rotary ❑ Air Rotary ❑ Auger' U Cable Tool U Push Point 0 Other Proposed Well Depth��Q_ft Excavation )-.2 in diameter l-Open Bottom PCGravel Pack/Gravel Size1/11" In diameter U Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter Jr in Thickness/Gauge/ASTM Sched��_ ❑ Steel $ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth -f ft ❑ Neat Cement(94 lb bag/5-10 gal water) /❑� Sand Cement sack mix/7 gal water >t9entonite(20%solids) �1 Other Grout Placement Method i.l Pumped i Free Fall Other E Retardant/Accelerator(name) II)EDESTAL Installed By ❑ Driller Pump Contractor ❑ Other , Concrete Pedestal;Dimensions:Width ft Length ft Thick in ❑ Christy Box P Stove Pipe I PLtF Submersible r; Turbine I 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. MHOUR ADVVCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 SIGNED TITLE / - j - / �wN DATE — r - it �Ahl JO Q IN C M N AL AEP RTMENT U E 9 NLY c Application Accepted By Date Area Employee ID#* Grout Inspection By 1 Date ll ❑ SPECIAL Well Permit Pump Inspection By a Date U (' ❑ WAIVER ReceiV Soil Boring Inspection 13v Date Constructed Wall—Depth ft COMMENTS C PE Sc R ceived Check Amount Date Permit/ Invoice# Well ID# Codes Info B Z ash Remitted Service Request# U 00 ?)!3 j � � I1" EHD 43-06 WELL/PUMP PERMIT 4/30/12