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F� d o SAN JOAQUIN COUNT,,ENVIRONMENTAL HEALTH DEPT '1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROMMM DATE ISSUED ADDRESS `LyCJ � f � � Imo\� � (1 l�� kV m o CROSS STREETd)ARCEL SIZE LAND USE APPLICATION# m en OWNER FLAME H Y-n CA Y\ �_o _Q Y� y R. d /PHONE.6Jb) `M OWNER:-:DDRESSCITYISTATEIZIP C: �_Cl l Or') CONTRACTOR PHONE CONTRACTOR ADDRESS CI1 Y/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFO MATION: Coordinates)( Y Township Range Section INT �iDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE Or WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of bodncds ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PaclVGravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Purnped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Boit ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other I-IP Pump S ft 'Standing Water Level ft 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL €3E 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. [tMNIMUM?�4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _ SIGNED TITLE DATE 10 IF p19 — H DA TMENT U E ONLY Application Accepted By Date Area Employee IDA A~ Grout Inspection By Date PECIAL Well Permit Pump Inspection BYZA. (A cwhnq Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info Q� Cash Remitted Service Request;? EHD 43-00 WELL/PUMP PERMIT 3/04/08