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�v a yWELL / PUMP PERMIT � 1J SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DETARTMENT 304 E WEBER ME 3M°FL-STOCKTON CA 95202 - (209)468$420 NON- EFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS . 1Pf — CITY/ZIP ✓ '� //I�1-r,//© �� �T 1 //L�r✓r V I//l CROSS STREET APN tY,3-1q0-© !5 PARCEL SIZE ad Z, AND USE APPLICATION# Am N m OWNER NAME _ PHONE 14 Ld- �J OWNER ADDRESS aI CITY/STATE/ZIP !n 7 R ODA ,.4 �0.-, jtq=CONTRACTOR ¢r PHONE CONTRACTOR ADDRESS I CITY/STATEIZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADD SS CITY/STATE/ZIP LICENSE 111<57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section_ ..� INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdifferentfrom Owner: Wet., ystem ame Contact Name or Phone Nuvn , TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) s ofbmings ❑Geotechnical s ofborings ❑Well Destruction ❑Out-Of-Service Well ❑Out- ervice Well Renewal ❑New Pum ❑Pum Replacement El Pump Repair ross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft 7� Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other y, Grout Seal Depth ft ❑Neat Cement(94 111 hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name Cl Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW MI U 24 HOUR ADVANCE NOTICE EQUIJ2ED FOR INSPECTIONS SIGNED TITLE �� , DATE ¢. JIN- O 1N G V RO DEP TMENT USE ON V - r"Ilq Application Accepted By Date 2- Z t Area C212—_ Employee ID# S.36�0 Grout Inspection By Date J�- .t��/.��,�1�' 13 SPECIAL Well Permit Pump Inspection By Date' r 13 WAIVER Received Destruction Inspection By // a Date Constructed Well Depth It , COMMENTS CM S PE SC Received eck# Amount Date Permit/ Invoice# Well ID# Codes Info By as Remitted Service Request# 9-322- /!3 L o END 4342- WELL PUMP PERMIT W&O"