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I WELUPUMP PERMIT SAN JOA;tUIN'COUNTY t.NVIRONIdENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 N-REFL1NDABLE PERMIT CALF 299 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 6/o i-Z�. CITY/ZIP r sz7,D m D 0 CROSS STREET r APN ��'2 PARCEL SIZE LAND USE APPLICATION# m OWNER NAME PHONE OWNER ADDRESS It�.i+t' CITY/STATE/ZIP CONTRACTOR A �—A JRrS a�i/z4aa--D�C PHONE CONTRACTOR ADDRESS /-V17(? CITY/STATE/ZIP V*;l W�aVp_ 01 5;L,50 0 SUBCONTRACTOR tj 327-3 / SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE b.,-,C-57n i rsC-57 C-61 D-09 Other NUMBER EXPIRATION DATE Co L.7 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE yeDomestic/PrivateXrrigation/Agricultural ❑ Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name --------C—ontact Name or Phone Number TYPE OF WORK AeW Well i Replacement Well ❑ Well Alteration/Modification 1-' Other ❑ Monitoring Well(s) #of wells i Soil Boring(s) #of borings i I Geotechnical #of borings ❑ Qut-Of-Service Well i Out-Of-Service Well Renewal i I Cross-Connection Repair °SINew Pump I Pump Replacement I Pump Repair I Raise Well Casing WELL CONSTRUCTION Drilling Methodsd2Mud Rotary I Air Rotary i Auger � Cable Tool i Push Point f Other Proposed Well Depth 3�ft Excavation in diameter i Open Bottom ixravel Pack/Gravel Size in diameter 1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 4C_ in Thickness/Gauge/ASTM Schede Z0 i Steel )d3lastic i I Stainless Steel Cl Other Grout Seal Depth_4w- ft I Neat Cement(94 Ib bag/5-10 gal water) .sand Cement f V zi sack mia17 gal water r' Bentonite(20%solids) I Other Grout Placement Method,►Pumped i i Free Fall i Other 1 Retardant/Accelerator(name) PEDESTAL Installed By Driller 1 1 Pump Contractor I Other ❑ Concrete Pedestal I Dimensions:Width « ft Length ft Thick if in 1 Christy Box -1 Stove Pipe PUMP ,�W.Submersiblei I Turbine i_ 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, S1 ATE 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. MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR�I^NSPECTIONS - PLEASE CALL(209)9533-7697 SIGNED z TITLE CC AJA-fl- DATE 7- 14 ILI yr1 DEP�A TMENT USE O //LY Application Accepted Date b Area._ _ Emplovee ID#_ESCeTrJ Grout Inspectio Date 4-114- < ❑ SPECIAL Well Permit Pump Inspection By Date0� 9111 ElWAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS viO224,C7D/�y � PE SC Received Check#/ Amount Permit/ Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# 7vd _' 0(� 110/ - EHD 43-06 WELL/PUMP PERMIT 4/30/12