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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �7 '�Z [] /� 'fess q N JOB ADDRESS / ! J / 'uS�`r \ CITY/ZIP��_t,_J�L�r �1"'�_/ r�� m 1 D CROSS STREET V') ' `IL,Y7�1 G APN Z--2-6- (5 C-2'7 PARCEL SIZE 3S'79 LAND USE APPLICATION# OWNERNAME �r ]`r-1 L-sasCiru PHON�2 � 599- 7-9t c) OWNERADDRESS -r CITY/STATE/ZIP N L (�-) � Y S��(1../�q CONTRACTOR PHOMe p - CONTRACTOR ADDRESS LS CITY/STATE/ZIP OI/\ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE ❑C-57 ❑C-61 ❑D-09 Other lJ NUMBER 6G233-L— EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USEDomestic/Private Irrigalion/Agricultumi ❑Industrial ❑Water Quality Monitoring [3 Soil Sampling/Characterization ❑Public Water System ber Ifdifferentfrom Owner Water System Nam ontau arae or one um TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #Of wells ❑Soil Boring(s) s ofborings ❑Geotechnical of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump Pump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sizein diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft n 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) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑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 HP Pump Set ft Standing Water Level ft \I 1 HEREBY CERfiFY THAT 1 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 COMPEN ON LAWS. MINI M 2'HOUR A ANCE NOTIC/E Ry�F_�,�UIRED FOR INSPECTIONS SIGNED -�� TITLES-fir-•� /�fA DATE-Tu, -rFT +�H N IR N E DEPARTMENT USE ONLY S Application Accepted By �-C� Date U a Lt(o Area Employee ID# lo�r 2 Grout Inspection By Date El SPECIAL Well Permit Pump Inspection By i _ L Date 3 ❑ WAIVER Received Constructed Well pth / ft COMMENTS PE SC Received Chec / Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# 4?-(`1 u5u v n So f-LJ161 EHD 43-02-M WELL PUMP PERMIT Ima005