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� WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L'S- tARTMENT 600 EAST MAI3..,aTREET-STOCKTON CA 95202 - (209)468 3420 NON-REFUNDABLE PERMIT yC�ALL(209 953--'7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM.DATE ISSUED JOB ADDRESS �al f k M" �J m CITYIZIP D PHONE a CROSS STREET / / APN PARCEL SIZE LAND USE APPLICATION# m OWNER NAME PHONE F � OWNER ADDRESS CITY/STATEIZIP CONTRACTOR � � � � '" .--f } CONTRACTOR ADORES r f CITYISTAT8IZIP r l .-$ ! / l✓ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP I LICENSE C-57 u C-61 ❑ D-09 ❑ Other NUMBE ExPIRATION DATE + GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section _ INTENDED USE ❑ Domestic/Private ❑ Irriga�ytio"_nlAgriculturai ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sam pli n g)Characterization ublic Water System �-D Gt S a 6-Lr 5 r^ E If different from OwnerWa er�ys eenlacme- Confact Name or Phone Number I TYPE OF WORK g New WeII ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑'Monitoring Well(s) #of wells ❑ Soil Borings) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair G New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method)(Mud 1Rottary ❑ Air Rotary ❑ Auger .E: Tool 11 Push Point El Other Proposed Well Depth '"{�V ft Excavation Ca in diameter i7 Open Bottom Gravel Pack/Gravel Size_ 0 in diameter ❑ Conductor Casing in diameter I Gond -or Casing Dept ! ft � Well Casing Diamete In Thickness/Gauge/ASTM Sched 1 t I teel YS lastic LiStainless St el ElOther Grout Seal Depth ft ❑ Neat Cement(94!b bag15-10 gal water) and Cement i- sack mix17 gal water 0 Bentonit (20°/o solids) Fj Other Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant I Accelerator(name) PEDESTAL Installed By ❑ Driller [1 Pump Contractor ❑ Other ❑ Concrete Pedesta)Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersibles Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT l 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 COMPENSA ION LAWS. IMUM 24 HOUR ADVANCE NOTICE QUI L>_FOR INSPECTIONS SIGNED TITL DATE:!t4k AVEllc DEP�ARTME-NT USE ON.L.Y _ K,e .� rr1'_ Application Accepted By Date Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well lD# Codes Info B Cash Remitted Service Request# EHD 43-06 WELL/PUMP PERMIT 810470B