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-2, WELL/PUMP PERMIT SAP'.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 JOB ADDRESS �bJJCITY/ZIP&ty1f—k/ W2 D CROSS STREETAPN7 � PARCEL SIZE f LAND USE APPLICATION# m y OWNER NAME PHONE:ZD4 1 � N OWNER ADDRESS NA 1,14 RD Ild CITY/STATE/ZIP CONTRACTOR PHONEE� CONTRACTOR ADDRESS CITY/STATERil` SUBCONTRACTOR �7`ZPHONEff SUBCONTRACTOR ADDRESS /A0 go/` J7 PITY/STATE/ZIP 1I LICENSE C-57 7 C-61 i 7 D-09 17 Other NUMBE XPIRATION DATE GEOGRAPHI AL INFORMATION: Coordinates X Y Township Range Section INTENDED USE U Domestic/Private Irrigation/Agricultural 11 Industrial C1 Water Quality Monitoring U Soil Sampling/Characterization I1 Public Water System If different from Owner: Water System Name contact Name or Phone Number TYPE OF WORK U New Well /S Replacement Well ❑ Well Alteration/Modification n Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings J Geotechnical If of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump Pump Replacement U Pump Repair n Raise Well Casing WELL CONSTRUCTION Drilling Method %Mud Rotary ❑ Air Rotary C Auger ❑ Cable Tool U Push Point ❑ Other Proposed Well Depth4:1C) _ft Excavation 1— in diameter U Open Bottom 0 Gravel Pack/Gravel Size M(a in diameter U Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter X in Thickness/Gauge/ASTM Sched 00 'j Steel *Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth -6PO It Neat Cement(94 Ib bag/5-f0 gal water) if Sand Cement f�•� sack mW7 gal water 1) Bentonite(20%solids) '1 Other Grout Placement Method j Pumped _-1 Free Fall ❑ Other f, Retardant/Accelerator(name) PEDESTAL Installed By E Driller =1 Pump Contractor ❑ Other Concrete Pedestal F Dimensions:Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP SubmersibleII Turbine I; Other --10 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 WORKCOMPENSATION LAWS. J Mm aM 2 O R ADVANCE NOTICE REQUIRED F INSP TIONS - PLEASE CALL(209;V17T97 SIGNED TITLE DATE 1 AV,Ph A. 1 � c 'A :,t M N D E P A R T M ENT I r C FP n_RI I v Application Accepted ' ate Area Employee ID# � Grout Inspectio y �� " -� Date ❑ SPECIAL Well Permit Pump Inspection By _ Date ❑ WAIVER Received Soil Boring Inspection By Date C nstructed Well Depth ft COMMENTS CGL PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Request# 3(c� 0 U C�O � - 3 °0 4/(jlko y�c��`I�53 W OVN 11 0 15, a y DU 3 8 EHD 43 06 WELL/PUMP PERMIT 4/30/12