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WELL/PUMP PERMIT SAN JOACUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / O D V ��V 15 I CI Cn,/ZIP f f 13 I �JZ D CROSS STREET APN 003 lJ Cl Z PARCEL SIZE _LAND USE Af/PPPLLI`C/A�TIjONN#-�f Q m OWNER NAME 1�20Ve ,1 AY�Y\-C _ f PHONE 11/7^J-r//-'I 10��7 P OWNERADDRESS �(�/7�VD rN D a V k IS - r`- CITYISTATE/ZIP/_O d j . I c' ' CONTRACTOR Y Y\GSC 1 1 1 ) [)r,I l`)11@ PHONE X22-- I q _123" om CONTRACTOR ADDRESS , l C� 1 \I b P(5 2 3 CITY/STATE/ZIP M„t f SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZJP LICENSE G57 C C-61 ❑ ❑Other NUMBER 6� EXPIRATIONDATE GEOGRAPHICAL INFORMATION: C00fdi6ates X, Y Township_ Range Section INTENDED USE n Domestic/Privrte Airrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization 7:PUb4c Water ystem If differnt from Tyner. / a er 5ySteM Name uontact Namo or Phone Number TYPE OF WORK New Well ❑Replacement Well 0 Well Alteration/Modification ❑Other Monitoring Well(s) #of wells ❑Soil Boring(s) a of borings G Geotechnical If of borings 7 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair ❑New Pum --O.Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRU TION ) Drilling Method ud Rptpy O f(ir Rotary 0 Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth 0 ft Excavation 2,7 in diameter ❑Open Bottom )�Gravel Pack/Gravel Size in diameter ,,CRDdtid a' in diameter / Conductor Casing Depth ft Well Casing DiamP r In ickness/Gauge/ASTM Schad O.25C Steel ❑Plastic 0 Stainless Steel ❑Other Grout Seal Depth ft C:Neat Cement(94/b bagi5-10 gal water) EI Sand Cement / C. 3 sack mixf7 gal water 0 entoni 0%solids) ❑Other Grout Placement Mathod , umped 0 Free Fall Cl Other ❑Retardant/Accelerator(name) PEDESTAL Installed By C Driller VPump Contractor ❑ Other Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box D Stove Pipe PUMP 0 Submersible n Turbine ❑Other HP Pump Set ft Standing Water Level it I HEREBY CERTIFY 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED ��C �� TITLE r 1 ``P r DATE J 13Ir1 pa N T DEPARTMENT USE ONLY Applicalion AcEeptea By _ _ Grout Inspection By/! SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspon By Date Constructed Well Depth ft COMMENTS PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Re uest# bbq 18 0 wl ) oo (P-71 49 i EHD 43-06 WELL/PUMP PERMIT RKMM