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R• WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzFLTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT �}CALL(20/9)953-7697 FOR INSPECTIONS EXPIRES'1^YEAR A/FROM 1DATE ISSUED JOB ADDRESS 1 v CrrY2T 1P { V -V CROSS STREET APN ,9 3(ua� PARCEL SIZEI�� LAND USEAPPLICATION# 9 (" c/� U ur OWNER NAME H�/(xXnU�'�(/I'I �r,,�W�J '^ PH�Oj�Nl,��I a2J , ` J�/l� y OWNER ADDRESS (l] L�)v {� 1 1 ��+� ✓ 1{ CI'tTYY/I/ST TE21P- Y ' CONTRACTOR _G,.J I-C 0'1/�• t L.Iy�'.�Q- 11J-11—. „oNE2�`t'�•`� ../35 CONTRACTOR ADDRESS IyV` �Y I Y(/LI�^yk-1 �"+ / • CITY/STATE21P o+ V�' _t- SUBCONTRACTOR r, PHONE SUBCONTRACTOR ADDRESS C'IN/STATE21P h 1 LICENSE C-57 L C-61 U D-09 U Other NUMBER!1 ��; EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USE Domestic/Private 7 Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization U Public Water System IfdBerent from Owner. Water SYSterl Nanle Conte ameor none a er TYPE OF WORK )(New Well L Replacement Well U Well Alteration/Modification U Other ❑Monitoring Well(s) #ofwells ❑Soil Borings) #of borings ❑Geotechnical #ofbodngs ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair U New Pump L Pump Replacement U Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Method NCMudary Air Rotary C Auger D Cable Tool ❑Push Point ❑ Other Proposed Well Depth, ',ft Excavation 2 in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter n Conduct r in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad n Steel n Plastic n Stainless Steel �Other Grout Seal Depth e4_ ft C Neat Cement(94 lb bao-10 gal water) ❑Sand Cement sack m/x/7 gal water Bentonite(20%solids) L Other Grout Placement Method KPumped ❑Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By D Driller XPump Contractor :1 Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP X Submersible?Turbine C Other HP Pump Set ft Standing Water Level ft 1 HEREBY1! TIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN U ORDINANC , STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRE N A TIVE WnyTHE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL W CO P NSATIO WS. IN IC UIRED FOVIINSP CTIONR7-PLEASE CALL(20 )953-7 9 TITLE 1��l� -�{ l f��f•)f'"1 DATE r UN 0 5 2018 tZ VIRpNM"O(ljq�' H HEPAR MFNT EPARTMENT USE }ONLY C / I �^ Date ,, Area Employee ID#Application Accepted By Grout Inspection By � Data_7& ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring InlPection By Date Const�jucted Well Depth ft COMMENTS Q�n6P A, (q l (1� 14Q/I./ n41'A"c, 0yp f I V PE SC Received Checkl Amount Permit' Codes Info B sh' Remitted Date Service R uest# Invoice# Well ID# 3Ec IK() rq 3e)7 41�u 0 U �� ti EHD 43-06 WELL/PUMP PERMIT 4130/12