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'R e 1 WELLIPUMP PERMIT N SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 96202-(109)468.3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N JOB ADDRESS /�OT / ��yl CrryF:4- "- `^� �S / O �tl1�N �p�• APNdA✓0 'V �� PARCEL SIZE� / LAND USE APPLICATION# y CROSS STREET49 /��9� - y OWNER NAME /ff4p,V .rig„y /�i►a.tE ��N� oC V��T - PHOr(Ef�-1 f CITYISTATEMP //7 // _ �f OWNER ADDRESS PHONE�`Df ~ �' A0 A CONTRACTOR CITYISTATFJLP S � 1ON OK/� �+�n A CA 9�370 CONTRACTOR ADDRESS •7 70 PHONE SUBCONTRACTOR CITY/STATEI2JP SUBCONTRACTOR ADDRESS x L DATE v I ' LICENSE C-57 I C-61 IID-U9 II Other NUMBER EXPIRATION GEOGRAPHICAL INFORMATION: Coordinate$X Y Township_ Range Section_. •"'� INTENDED USE ❑DOmestlC/PfiVale gallon/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soli Sampling/Characterization _ ❑Public Water Sysle a er y em ame o • ams or one u r • --•t If dlHerent t—Owner. TYPE OF WORK New Well C Replacement Well D Well Alteration/Modificagon s of bornIher a of borings . •'y” ❑Geotechnical -y ❑Monitoring Wells) #of wells 7 Soil Boring(s) -7 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair ❑New Pump ❑Pump Re lacemenl ❑Pum2 Repair C Raise Well Casingria LC �- Drilling Method vlud Rotary ❑Air Rotary ❑Auoer -)01 7 Push Point O Other i Proposed Well Depth SSW Excavation f t .•ameter X Open Bottom 7 Gravel Pack/Gravel Size In th lel CID t, Conductor Casing In diamdter X Conductor Casing Depth Re ft - Well Casing Diameter (4y In Thickness/Gauge/ASTM Schad�_ teel ❑Plastic C Stainless Steel 7 Other ?y v r -+� sack mi/7 gel water >e t 6 yL Grout Seal Depth~_L J IC ft -1 Neat Cement(94 Ib bag/5-10 gal water) Sand Cement j � 0 Bentonite(2u�solids) 0 Other ti~2 u Retardant/Accelerator(name) :a.orva Grout Placement Method'�umped u Free Fell ❑Other 4'. CA'Al PEDESTA Installed By C Driller 7 Pump Contractor ❑ Other ^� 1j ❑Concrete Pedestal Dimensions:Width R Length R Thick In C Christy Box C Stove Pipe PUMP ❑SubmersibleC Turbine ❑Other HP Pump Set ft Blanding Water Level 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. MIN MUM 24 HOUR ADVANCE NOTICE REUIRI�D FOR INSPECTIONS DATE ✓�_ SIGNED LTITLE Ac�ENT VFD IyQUIN CQ MUNTM DEPARTMENT USE ONLY Application Accepted By J C-1 - Date r S Area > 6(� Employee ID# Grout Inspection By Date ❑ SPECIAL WeII Permit Pump Inspection By Date ❑ WAIVER Received Spate Cons cted Well Depth ft i ��r M oil Boring Ins action By �'7 r,,.....-NTS "� iN 5 4.�t L{�f/' DAA b.i;�i �,•trL�L� ` b n,y. n (v, _ _ _�►+-_ _.... Well ID# r� Amount Date Invoice# Codes Into B Gash Remitted Service Re uest# 400 WELL/PUMP PERMrT EHD 43-0e 8/04!08