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` WELUP UMP 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 JOB ADDRESS �6 119 {O L��-/ Nl//J��/ �L�G] /«1 CITY/ZIP 1j�/�G � �/Ti �� / v CROSS STREETT VC�LA T7 r� APN !l"6 0�DbD -V�PARCEL SIZE 16.0"0 LAND USE APPLICATION# M OWNER NAME /,,*� 1S�C/Wo-ke S NA M If ry;� C �PHH/O�NE� �G//' r7V OWNER ADDRESS 2 Y/ /2-<0 15^U M 1,ft ' r E� r& CITY/STATE/ZIP 7ZA-c!1 C4 '75 3'7 7 CONTRACTOR ��J ✓f7 /�Ci PHONE � 7 7 Z ' ZZ S-7 CONTRACTOR ADDRESS 06106 CITY/STATE/ZIP1,14ele, S� -/5-29—2 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE �C-57 l C-61 i 1 D-09 (1 Other NUMBER EXPIRATION DATE a� 2,01,9 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE X Domestic/Private [1 Irrigation/Agricultural ❑ Industrial is Water Quality Monitoring ❑ Soil Sampling/Characterization (l Public Water System If different from Owner: Water ystem Name ontact ame or Phone Number TYPE OF WORK C] New Well I l Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump ,�[Pump Replacement ❑ Pump Repair 11 Raise Well Casing N Drilling Method ❑ Mud Rotary [5 Air Rotary ❑ Auger ❑ Cable Toot U Push Point ❑ Other Swpwiiiiiiiiid Well Depth 20 2 It Excavation in diameter -3 Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel %Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft C1 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water (_I Bentonite(20%solids) �1 Other Grout Placement Method i 1 Pumped Free Fall F Other 11 Retardant/Accelerator(name) PEDESTAL Installed By [j Driller ; Pump Contractor ❑ Other Concrete Pedestal .Dimensions:Width ft Length ft Thick in ❑ Christy Box P Stove Pipe PUMP OK Submersible Ll Turbine r; Other HP-/y2 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. MI U 24 H DV NCE NOTICE REQUIRED FO INSPE TIONS - LEASE CALL (209)953-7697 SIGNED TITLE i DATE 7 A J Ito. VR C U D pq L 1 0- iJ EP� ARTh' GPlT l SE ONLY Application Accepted B Date Vih -7 Area *Iqll Employee ID#6 �� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date td ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Receivedhe Amount Date Permit/ Invoice# Well ID# Codes Info B sh Remitted Service Request# <S27 Sr 0038292 EHD 43-06 WELL/PUMP PERMIT 4/30/12