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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D IVARTMENT 304 E WEBER4E 3X0 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS 1 lJ J �, 1 �], �� = CITY/ZIP L- (L i C71 r)2-L-1Z > V r ° 4 I PARCEL SIZE ' LAND USE APPLICATION# CROSS STREET �U�� XZ(.�C�i (1.�i1t'C PN C-i5�- LSA' -1� 't OWNER NAME Tr,\'Yl �C�'�-'��`�C�11 PHONE OWNER ADDRESS ��(7!-7 s) 1�: �� i�� -J� Cp�L� �'ITY/STATE/ZIP 1-t!" CONTRACTOR �. l�C(L'� ��\ \_L.crtt- �` iPIIONE L Gi.J/,'t, CONTRACTOR ADDRESS—?n s r7(37l � � CITY/STATE/ZIP �i-Cic C� `k SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 El C-61 ❑D-09 21'Other 7 Li Cj.i -V-15j G NUMBER '7 5jg EXPIRATION DATE -3 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different fromOwner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ell Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings ❑Well Destruction � 11Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pum SifPum Replacement ❑Pump Repair ❑Cross-Connection 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 Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other cj Grout Seal Depth ft ❑Neat Cement(94/h hub/S-/0 ga!water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) r PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width tt Length It Thick in ❑Christy Box ❑Stove Pipe PUMP S Submersible ❑Turbine ❑Other HP Pump L Pump Set C) ft Standing Water Level �ZZ� ft A 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 LAWS. MINI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED / TITLE �jj��l:lllCL�'1CfC -I�JI— DATE i, "` L-'�t"'1 T r 1 t O LA1 �a tN a I DEPARTM E NT USE ONLY Application Accepted By Date It h�0 Area oZ-1 Employee ID# s 3 C,C, l Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By `•�,��:�CCt `)tit'w �� Date 17-i3 O`1 ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC ReceivedCheck#/ Amount Permit/ Codes Info By Cas emitted Date Service Request# Invoice# Well ID# q3 f,1 o EHD 43-02-006 WELL PUMP PERMIT 9/6iO4