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V t 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 Ln JOB ADDRESS /t r /�L'U P l 7 "- �yN %.S S m CITY/ZID CROSS STREET k" A P N /JJ �v hh PARCEL SIZE LAND USE APPPLIICCATION# ) �/ m �) H U U 2 `PHONE" OWNER NAME ✓��P� /► / �t OWNER ADDRESS Z '4A/// /� 0/STATE/ZIP CONTRACTOR �� %/�` �� I'I PHONE Z14f CONTRACTOR ADDRESS ��/�>rn �v CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 1 C-61 1 D-09 11 Other NUMBER /&)Z2:!ZZR EXPIRATION DATE P GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ?A Domestic/Private ❑ Irrigation/Agricultural U Industrial L; Water Quality Monitoring ❑ Soil Sampling/Characterization [1 Public Water System If different from Owner: Water Syslem Name --------Co—niact Name or Phone Number TYPE OF WORK F] New Well I 1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings L Geotechnical #of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump a Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary h Auger ❑ Cable Tool L] Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter u Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 'i Steel ❑ Plastic C Stainless Steel 0 Other Grout Seal Depth ft 'i Neat Cement(94 lb bag/5-f0 gal water) ❑ Sand Cement sack mix/7 gal water 1..I Bentonite(20%solids) U Other Grout Placement Method [.] Pumped .D Free Fall I-, Other U Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 7] Pump Contractor ❑ Other Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible[.1 Turbine I; Other HP 2— Pump Set ' ft Standing Water Level /Z '7 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 CO TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMU 4 R ADVANC O E REQUIRED FOR (INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED c� TITLE J��/ ��r`'� DATE // �/a /7 i I FH+1 �l c \) � P f D PARTMENT USE ONLY Application Accepted By Date �/ 0 i Area Employee ID Grout Inspection By Date ❑ PE IAL Well Permit Pump Inspection By M1) "MALAW Date U`") ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS��`�� L �0��W��O)ML.C�� PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 'Q1) 4607 EHD 43-06 WELL/PUMP PERMIT 4/30/12