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WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 20/9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 �G v TY� CITYZP _ _3 a 0 CROSS STREET AP( �� PARCEL SIZED LAND USE APPLICATIO`N�# 9 OWNERNAME M /rlUu'�'• 1 t`K]�UIJ f^ ''�'�P/H/O,,N—'/� , 2?J % 36—k N OWNER ADDRESS � U 1/) 1 1 ,�--�"nl�+� Y I I /�) CI'rTYY/SSTASE IPt_— �`1"" y 1 C " I ", 'I x �'7 fir[ CONTRACTOR CIL) 1 `t�L�^ y'C�I IJI l l `lf 1.L HHOONE2-0q• U 31� l L CONTRACTOR ADDRESS I V V L �G Y!/i.I�Y-) � 4=t A CITY/STATE/ZIP "✓'�c) V r� l SUBCONTRACTOR �! r, PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP G h LICENSE C-57 L C-61 U D-09 U Other NUMBER�! �� EXPIRATION DATE _ l 'z V GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ INTENDED USE Domestic/Private 7 Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization U Public Water System Ifdffferent from Owner. Water System Name Gontoot Name or Pnone um er TYPE OF WORK XNew Well L Replacement Well U Well Alteration/Modification U 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 U New Pump L Pump Replacement U Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Method)CMud doary C Air Rotary C Auger 7 Cable Tool ❑Push Point ❑ Other Proposed Well Depth 4!�L7 ft Excavation I Z in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter n Conduct r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter In Thickness/Gauge/ASTM Schad n Steel n Plastic n Stainless Steel -t Other Grout Seal Depth_,- ft C Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mixl7 gal water Bentonite(20%solids) L Other Grout Placement Method KPumped ❑Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 7 Driller X Pump Contractor 7 Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible]Turbine C Other HP Pump Set ft Standing Water Level ft I HEREBY ERTIFY 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 WIT HE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL W CO P NSATIO WS. IN I UIRED FOTVINSPE CTTIONq-PLEASE CALL(20 )953-7r9 , TITLE 1JDATE l . PAY�E1V T UIy 0 5 2018 VlRotiM COUNTY H DEPgRMENl' EPARTMENT USE ONLY / Application Accepted By •r I L JDate "/J V Area / Employee ID#–A/1 rn C Grout Inspection By 14d& Date. /I _ ❑ SPECIAL WEII Permit Pump Inspection By Date sr �� ❑ WAIVER Received Soil Boring Inspection By Date Const cted Well Depth ft COMMENTS Rtdl..0 (',qI ( j�o(f/�C'dl, 0!i'/Dj I� PE Sc Received ` Chec�b Amount Permit/ Codes Info B "cash' Remitted Date Service Request# Invoice# Well ID# 411) O JG / S' CL =3 �i3gl y EHD 4306 WELL/PUMP PERMIT 4130/12