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` S 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 n 1 A to JOB ADDRESS � 751/ � J -Q t�C�l CITY/ZIP (4; i CH 9�-2-y C-) - D �� tt O �- 102 PARCEL SIZE il ? #LAND USE APPLICATION M CROSS STREET 0\I4,0-,4 C6I COY 1�.I,y► APN t`_ m OWNER NAME ��CQ P Vnaur j C1VlClS PHONE Am OWNER ADDRESS kk-7 J 1 a c�G t`�^TGYI.0 Rd CITY/STATE2IP / n,I;, C s tAo-ye-C, 20 9-�I r7 0- (o9j H t CONTRACTOR �r PHONE 11 CONTRACTOR ADDRESS (_2Oi__ CITY/STATE2IP 4' '_r , SUBCONTRACTOR / 7 PHONE SUBCONTRACTOR ADDRESS �j CITY/STATE/ZIP LICENSE r! C-57 r I C-61 I D-09 Other G��`� NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE V Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization n Public Water System If different from Owner: Water System Name contact Name or Phone Number TYPE OF WORK -1 New Well r i Replacement Well ❑ Well Alteration/Modification Other ll. r'P_PCk_jj- 0 :1Monitoring Well(s) #of wells ❑ Soil Boring(s) #of rorings ❑ Geotechnical of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pum ❑ Pump Replacement )(Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Cl Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter U Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic 0 Stainless Steel ❑ Other Grout Seal Depth ft C? Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water [.I Bentonite(20%solids) �I Other Grout Placement Method [U Pumped '� Free Fall C. Other a Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller :1 Pump Contractor ❑ Other Concrete Pedestal ;:Dimensions:Width ft Length ft Thick in ❑ Christy Box n Stove Pipe PUMP Submersible Cl Turbine r' 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 COMPENS ION LAWS. MI UMUHOU ADV NCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 953-7697 SIGNED TITLE VW�/fCc f`QC`Fc��r�/ DATE I /R p TIFq E T FFF DEPARTMENT U E NLY Application Accepted By I Date 15�A.'0Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date D f ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS _ PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# EHD 43-06 J I WELL/PUMP PERMIT 4/30112