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or , 1%, 1 �('%A VC11 WELUPUMP 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 A 5 Zt [n/ JOB ADDRESS � 1 I b� my� CITY/ZIP'C'iuc _\ W 1 .! ! \ m V CROSS STREET '(, APN ' 7 PARCEL SIZE NO USE APPLICATION# a """'��III N OWNER NAME PHONEavi 'DC1L f a N OWNER ADDRESS VAA(�1 Ill'[.�'1 { CITY/STATE/ZIP i 1 .7y CONTRACTOR C/�(,�11L �/�(�Yt�1� �YU`f +V[[�\lo-, G �/ln L JV L\�\ II, ` l�J 11��L1-• �-�pC�� CONTRACTOR ADDRESS I l `Y �J 4J \ ✓ CITY/STATE/ZIP �)�T.�J •"• c ' '- fes. SUBCONTRACTOR PHONE YV N SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 L C-61 L D-09 L Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates Y Township Range Section INTENDED USE omestic/Private 7 Irrigation/Agricultural ❑Industrial -]Water Quality Monitoring L Soil Sampling/Characterization Lj Public Water System If different from Owner: Water 5YStern Name one arae or 11hone Number TYPE OF WORK New Well L Replacement Well L Well Alteration/Modification a Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #ofbonngs ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair L New Pump L Pump Replacement L Pump Repair LI Raise Well Casing WELL CONSTRUCTION Drilling Method PS.Mud Rotary L Air Rotary C Auger L Cable Tool ❑Push Point ❑ Other Proposed Well Depth j2 Qj ft Excavation in diameter L Open B it L Gravel Pack/Gravel Size in diameter n Conduc or Casing in diameter / Conductor Casing Depth ft Well Casing Diameter I k ss/Gauge/ASTM Sched n Steel Plastic n Stainless Steel Other Grout Seal Depth L Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water Bentoni a(20%soli s) L Other Grout Placement Method umped ❑ Free Fall E Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller L Pump Contractor L Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible-ITurbine C 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 0 DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AN C WITH TH ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS C M E A ION LAW . I I U 2 HOU DV IRED FOR INSPpE/CTIIIONS\-PLEASE CALL(209)953-T697 SIGNE TITLE,.A}�Y�-r,7 I_►JY `� �Y DATE v r IyLr Z 18 0 uN� �Pp.A DEPARTMENT USE Application Accepted By i Date 'r Area C` Employee ID# " �' Grout Inspection y Date ❑ $PECI L Weil Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed W 1 D th ft � MMENTS PE Sc Received Chec Amount Date Permit/ Invoice# WeII1D# Codes Info B Cash Remitted Service Request# ego 3e` w � P EHD 43-06 WELL/PUMP PERMIT 4/30/12