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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)469-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos ADDRESS 72-57 ES(.�lA�� l lt�-��(�� CITY/ZIP r L . (/11}�6-33 l m o CROSS STREET f APN 2(e— CJW�'Ute'PARCEL SIZE 2-L' LAND USE APPLICATION# M OWNER NAME 1 1-..17 y,i PHONq/n9) 7-,7,9-1792- /y2- " OWNER ADDRESS CITY/STATE/ZIP j C a CONTRACTOR11.. '1� r^- �- PHONt��/�� CONTRACTOR ADDRESS I t� VS 7"\C1 1f) CrrY/STATF/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP f LICENSE 13C-57 13C-61 13D-09 Other_ NUMBER �n n L 1�Z EXPIRATION DATE 1 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System IfdilTerent from Owner. W.w Sysm. .me Comwt Name or Phone Numba TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) r of borings ❑Geotechnical #ofborines ❑Out-Of--ServiceW I ❑Out-Of--Service Well Renewal 13 Cross-Connection Repair C3 New Pum Pump Replacement ❑Pump Repair J WELL CONSTRUCTION N Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other �1 Proposed Well Depth It Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter J ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Scher! ❑Steel ❑Plastic ❑Stainless Steel ❑Other r('1 Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(200/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) V^) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other �. ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other HPy Pump Set ft Standing Water Level I HEREBY CE TIFY 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 l WORKERS COMPENSA ON LAWS. MINI UM 24 OUR VANCE NOTICE R QUIRED FOR INSPECTIONS / SIGNED TITLE Pi)- DATE C_� I V1 14 . 11 .1 1 J DEPARTMENT USE ONLY S Application Accepted By Date Z' �l C�' Area Employee ION `�L 4S p/p Grout Inspection By Date r ❑ SPECIAL Well Permit Pump Inspection By Date 3 lee ❑ WAIVER Received Constructed Wellepth ft COMMENTS PE SC Received Check#/. Amount Date Permill Invoice# Well ID# Codes Into B ash Remitted Service R ueat# C, t5 10 21 s,.to (,)o6 6eM Y 6 72- ERD 43-02.006 WELL PUMP PERMIT Imnoos