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F WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 9868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED v, 3(oaoC7 S. Calls � � u c 1 R53"j JOB ADDRESS CITY/ZIP m D �y/_/ snI �J/�) 0 CROSS STREET APN; v w OlO PARCEL SIZ90v- AND USE APPLICATION# G�Fj� / m OWNER NAMECn PHONE—U 35� 5� 3t'I P OWNERADDRESS r5 CITY/STATE/ZIP 1 ,e (�1 '2�77 CONTRACTOR ^WmAtann PHONE �D zy/ '3 CONTRACTOR ADDRESS o2 CITY/STATE/ZIP Com.C.A4 SUBCONTRACTOR A on PHONE 04 44 SUBCONTRACTOR ADDRESS CI Y/STATE/ZIP LICENSE 3%57 ❑ C-61 ❑ D-09 ❑ Other NUMBER ExPIRATION DATE--L-3/- GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: a er ys em Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ 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 ❑ New Pump )(-Purnp Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ IVlud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacldGravel 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/b 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 Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other IIP Pump Set ft -Standing Water Level ft 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 T HAT.I AM IN COMPLIANCE WITH ALL WORKE OMPENSAIION LAWS. 10 UM X HOURADVANCE NOTICE EQUI D FOR INSPECTIONS SIGNED TITLE ZRAV" DATE "1 10000 nt S � D PA TMENT U E ONLY HEq/ DQ�ppM��r�N1Y Application Accepted By Date Area Empldy( ,� Grout Inspection By Date ff ff PECIAL Well Permit Pump Inspection By r��r��}to c `au Date 3/ 1'l01 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth fid COMMENTS PE SC Received Amount Date Permit/ Invoice# Well ID# Codes In`ro BY Cash Remitted Service Request# WP00 40493 EHD 43-06 WELL/PUMP PERMIT 8/04/08