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rr10, WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ORKRTMENT 304 E WEBERIw at 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED y JOB ADDRESS ��O / O 144 r�� CITY/ZIe `l J aY CROSS STREET Ar�rfT��'iyr�,� � ,A-PCNL I�� I PARCEL SIZE Io.z LAND UBE APP/LIGATION# / OWNER NAME t-�7>•7T.A771y—.17�I TPHONE (OO o- / m OWNER ADDRESS In CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITYISTATE/Z/P I SUBCONTRACTOR P 1 /1 PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 -61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Chameterimtion ❑Public Water System Ifdifferentfrom Owner: waw system Nam ntact araeor one um r TVPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of bodegs ❑Geotechnical #afborinp ❑Out-Of-Smite Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ew Pum 9(P—Ump Replacement ❑Pump Repair WELL CONSTRU&ION 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 Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth It ❑Neat Cement(94 Ib bag/5-10gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20a/solids) ❑Manufacturer Spec%solids_% Name ❑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 It Length It Thick in ❑Christy Box ❑Stove Pipe OM Submersible ❑Turbine ❑Other HP-�=Pump Set It Standing Water Level ft I 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. 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 COMPENSATION LAWS. Ml>iMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ) p SIGNED 94(VTITLE DATE —/ V ALS V 1 C t) S N E vt Fill E\P RTMENT VSY ONLY Application Accepted BATA Date 21 f I I Area Employee ID# /J Grout Inspection By Date [tJ� � 13 SPECIAL Well Permit _(C/ Pump Inspection B Date- 1=r-� ❑ WAIVER Received Constructed Well Depth ft COMMENTSJ� `1 PE SC Received Check# Amount to Permit/ Invoice# Well ID# o es I Info B ash Remitted Service Request# WELL PUMP PER611T EHD 4302-006 127/2005