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ELL / PUMP PERMIT JUIN COUNTY ENVIRONMENTAL HEALTH DEP.:I?RI.KNT 304 E WEBER AVE V.(i'L-STOCKTON CA 95202 - (209)468-3420 REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED y ADDRESS II 21L1' 1 CITY/ZIP��(1►>I 6 Ll > v L _ v ,ROSS STREET L)I ej LAPN " )�=rl� RC EL SIZE .LAND USE APPLICATION# c �`l '�/ /� rn OWNER NAME _�A& S ii �" t l r'��C�I/� _ ((P�H/ONE 1oe-1- /ke' �1( l' %" CITY/STATE/ZIP `LCC 3"" i _ 7�3 OWNER ADDRESS �� Iz PHONE CONTRACTOR CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICALINFORMATION: Coordinates X Y Township Range Section --�. INTENDED USE ❑Domestic/Private iKIrrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well g Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair (� ❑New Pump ❑Pump Replacement ❑Pump Repair ` WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other - Proposed Well Depth ti Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter �1 ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched_ ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Scat Depth fl ❑Neat Cement(U4 lh hag/5-10 gal truier) ❑Sand Cement ----suck mn/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Rcta nt/Accelerator(naitTa PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width 11 Length R Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other IIP Pump Set yL% ft Standing Water Level zn R 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK HILL 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 COMPENSATION L WS. MUM 24 HOUR ADVANCE NOTICE RE\QUIpRED FOR INSPECTIONS SIGNED _ TITLE /GoN� F—� DATE i aL tit.l JO\(�lll^i C:UUNiY E Vl it/ ?,A NTAL TMENT FT TT D P A R T M E N T U S E O N V Y Application Accepted B}�r 1 to Area_Ls Employee ID#_�a� Grout Inspection By Date ❑ SPECIAL Well Permit yh7 Pump Inspec 'on B Date 157301-6 ❑ WAIVER Received Constructed Well Depth ft COMM-'NTS T PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# EHD 43-02-006 WELL PUMP PERMIT 127,20M