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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 ' JOB ADDRESSf en (I EA CITY/ZIP CROSS STREET *r I PJrI �l l APN o2Q 1�� ID—d� PARCEL SIZE �fl LAND USE APPLIC/ATIOON# 2 m OWNER NAME '`� ` u U �T PHONE Sit)—(R7— ✓ � OWNER ADDRESS tqI ?l ��,,0, l��(l� Lt\ �q CITY/STATE/ZIP anfi�� CONTRACTOR ! 1 LSI��I/I� '^C_ �/l JJ• - Yl { �! l ��r� //PHONE CONTRACTOR ADDRESS I"/.2, J " - CITY/STATE/ZIP, SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS .CITY)/STATE/ZIP LICENSE 2-57 r1 C-61 J D-09 [l Other NUMBER DO /5 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE X-pomestic/Private ❑ Irrigation/Agricultural ❑ Industrial [i Water Quality Monitoring U Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name ontactName or Phone Number TYPE OF WORK New Well P Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U Geotechnical N of borings ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal ❑ Cross-Connection Repair P, New Pump El Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method)(Mud Rotary ❑ Air Rotary ❑ Auger Ll Cable Tool U Push Point ❑ Other Proposed Well Depth_�2'0b ft Excavation14 in diameter [I Open Bottom Gravel Pack/Gravel Size Iv In diameter U Conductor Casing in diameter / Conductor Casing Depth ft .5alw(f'CL�C Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched�!� ij Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 2ibD ft Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water X Bentonite(20%solids) t 1 Other Grout Placement Method XPumped ❑ Free Fall F Other 1.1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller X Pump Contractor ❑ Other Concrete Pedestal;-Dimensions:Width ft Length ft Thick in ❑ Christy Box n Stove Pipe PUMP C Submersible I j 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 COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIR D FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED - Q tO TITLEy, DATE— 0. HF—F — DEP RTMENT USE ONLY lqoj Application Accepted By Date Area Employee ID# 0� Grout Inspection By Date SPECIAL Well Permit �� Pump Inspection By Date Q WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft CO M NTS 77 7 .See-Gt i o4,t ..�i.. �or.... PE Sc Received Check Amount Date Permit/ Invoice# Well ID# Codes Info B s Remitted Service Request# �S EHD 43-06 WELL/PUMP PERMIT 4130/12