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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 2 9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N JOB ADDRESS -5 \ `y�-5 rh CROSS STREET AQP^ �.�J�PARCEL SIZE LAND USE APPLICATION# M OWNER NAME / PHONE 34 7 OWNER ADDRESS IC - CRY/$TATE/ZIP \ T CONTRACTOR HON w CONTRACTOR ADDRESS _ CITY/STATE/Z1P S SUBCONTRACTOR _ __. PHONE SUBCONTRACTOR ADDRESS - - Crry/SSTTATE/ZP}�Iiy.--� LICENSE -57 -61 0 D-09 0 Other NUMBE�! ��U -1 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ INTENDED USE 0 Domestic/Private rrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization 0 Public Water System It different from Owner: Wafer System Name Gonlacl Name or Phone Number TYPE OF WORK )(New Well 0 Replacement Well ❑Well Alteration/Modification 0 Other_ PAYMENT 0 Monitoring Wells) #of wells ❑Soil Boring( ) ❑Geotechnical Rs #of borings ti:,; ED CtwrtC 110 ❑Out-Of-Service WeII ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair JUL 2 5 2013 New Pum 0 Pum Replacement ❑ Pum Repair 0 Raise Well Casing WELL CONST R C ON c'�r'�— SAN JOAQUIN COUNT Drilling Method Mud Rote; ❑Air Rotary 0 Auger 0 Cable Tool ❑Push Point ❑ Other y,IRneAFa[TAI Proposed Well Depth k Excavation in diameter 0 Open Bottom Gravel Pack/Gravel S#gA VEPA'OTT 0 Conduct Casing in diamete�nductor Casing Depth it Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel,*lastic 0 Stainless Steel 0 Other Grout Seal Depth It 0 Neat Cement(94 lb bag/5-10 gal water) ('Sand Cement I(✓^• 3 sack mbd7 gal water 0 Bentonite(20%solids) 0 Other Grout Placement Method umped 0 Free Fell 0 Other 0 Retardant I Accelerator(name) PEDESTAL Installed By K.Driller 0 Pump Contractop j o Other 0 Concrete edesta)Dimensions:Width Zt it Length it Thick in ❑Christy Box ❑Stove Pipe PUMP Submersibleo Turbine 0 Other HP-0—c— Pump Set ' tt Standing Water Level ft I HEREBY CE TIFY THAT I 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI IM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED ` — ��.�/L.e_� TITLET/`�• 1. r DATE r i V-31 Y il l 1.6 ) DEPARTMENT USE ONLY U J ' Application Accepted B Date Y Y 3= AreaEmployee ID# Grout Inspection Date !8 ❑ SPECIAL Well Permit ' Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Dep h ft COMMENTS OI Lo( Ali ,e flr T'L ,� bYI4917% T%1G/GL L tn'�ifSZLr 1 G!J 2W'�S GT' PE SC Received C_2teSW Amount Permit/ Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# gbh so 47736 3�1r• �as�i3 5TZo b1651 '7730 53^ 7 --;go 0 6-7 6!;