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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 Sc Received Info B JOB ADDRESS • CITY/ZIP� ii 1'�-C.� r✓ i 1 m .In1 - CROSS STREET " al' I �ND a 0 °a APN V ARCEL S¢E USE APPLICATION #� B //�� OWNER NAME f/l. I • p� /1� jP�HONEIU+ OWNER ADDRESS 0 C I w CrTY/STATE/LIP C/ -'c u I-v.n^ . o'o q�3 !-'l CONTRACTOR ,11- `tel -e-+L' \ 7 V I �1 GO V1 PHONE ki 1�V�J� CONTRACTOR IL1 ADDRESS l 21 IL I CrTY/STATE/ZIP ^^(y1 SUBCONTRACTOR 1V PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 1 1 � ,t 1 LICENSEC-57 t.. C-61 L1 D-09 Li Other NUMBER ExPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates Y Township Range Section_ PE ( vo"IM Ix V#� by t INTENDED USE ❑ Domestic/Private Vrrigation/Agricultural ❑ Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization u Public Water System If different from Owner: a er System eme on ac Name or one um r TYPE OF WORK XNewWell L Replacement Well c Well Alteration/Modification a Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) If of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair u New Pump L Pump Replacement a Pump Repair a Raise Well Casino Drilling Method %F Mud Rotary C Air Rotary C Auger 7 Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ()Q ft Excavation �a_ in diameter a Open Bottom a Gravel Pack/Gravel Size in diameter F1 Conductor Casing in diameter / Conductor Casing Depth it Well Casing Diameter 1 tP in Thickness/Gauge/ASTM Sched Steel n Plastic ❑ Stainless Steel -1 Other Grout Seal Depth 50 It C Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite (20% solids) L Other .tel Grout Placement Method)( Pumped ❑ Free Fall C Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By 7 Driller C Pump Contractor 7 Other ❑ Concrete Pedestal []Dimensions: Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible] Turbine C Other HP Pump Set ft Standing Water Level ft I HEREEBBY CTI HAT 1 HAVFfP EARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN q0IIjNZRDINANC��({/ST E LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS E CURB T WITH E C LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL RED FOR IINS�rP�EEC�TI NS - ( tE�A/S/E CALL (209) 953-7697 TITLE 14J& �- \ P� ` _ ` DATE E RTMENT S-�414 L Y �t�� Application Accepted Data Area e^J[ Employee ID# f1 Grout Inspection By Date ❑ `SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection Qy /[DConstructed Well Depth ft COMMENTS ,A L•t �L` `' ate L - PE Codes Sc Received Info B h Cash Amount Date Permit/ Invoice# WeII1D# Remitted Service Request #fq�ff: LIA-� -bq EHD 43-06 WELL /PUMP PERMIT 4/30/12