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—j-11T/VCU WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH b ARTMENT 304E WEBEi, E3"PL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR RO D TFL I ED uury JOB ADDRESS -/ -N' `" •VL 0' Crrrr�Y/ZIP O V�'P /� APN 1�/ f�DSO/PARCELSIZE �/rS— LAND USE APPLICATION# CROSS STREET Q`� y OWNERNAME ��AY l ,06 6S �� PHONE O +9— �l0 / K OWNER ADDRESS �r CITY/STATE/ZIP iv& PHONE 7� �T CONTRACTOR ` a:i �"'STPH/O�N/E�� CONTRACTOR ADDRESS C6 O CITY/STATE/ZIP x torL� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS iP CITY/STATEIZIP Q LICENSE ❑C-57 ❑C-61 ❑D-09 ther NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ INTENDED USE ]lQHomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization /❑_Public Water System Own If diRerom from r: Waw symm Its. onuct eme or M u TYPE OF WORK ❑New Well ❑Replacement Well Nell Alteration/Modification ❑Other V ' ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofboring. ❑Geotechnical #ufbon., ❑Out-Of-Service Well ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair O ❑New Pump ❑Pump Replacement ❑Pump Repair 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 Sim in diameter w ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 1b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted A Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP >nubmersible O Turbine ❑Other HP----L—Pump Set R 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. I 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 COMPENSATIObj LAWS. UM 24 HOUR ADVANCE NOTICE�tEQU ED FOR INSPECTIONS 15 /fp SIGNED TITLE �-- DATE G J P• N E O 2DEARTMENT USE,,ONX'Y USE ON �/[} Application Accepted B to Area I ✓ Employee ID# r r /Y—y Grout Inspection y Dale ❑ SPECIAL Well Permit Pump Inspection By rAle A/ Dated 21)4-6 ❑ WAIVER Received Constructed Well � rI, it COMMENTS /✓ � A ,& L. AA% w.b f`' rnl �eA C)416M 10e to - s PE SC Receivedh Amount Date Permit/ Invoice# Well IDN Codes Info B Cash Remitted Service Request# U SSC 4-z5c- EHD U-02-006 WELL PUMP PERMIT lWaW5