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p7lc^ WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED t JOB ADDRESS W4A hyV,p t �5/'�' I ` CmvrzlP L3 V I CA 1924-L � �/� � II t/��qp/-G/� 0 CROSS STREETDAV( APN PARCEL SIZE W�ZANDUSEE-APPPLLICATION# / m OWNER NAME w��v ��7 �' •W+�t PHONE / / � -��v� •�A• OWNER ADDRESS J�/S Z / 64 A L J y� CITY/STATEIZIP Z0(/ / CONTRACTOR /�r 4r� �y�J�S &L4"/ PHONE 3/.�J•��y'- `l7 ' CONTRACTOR ADDRESS CITY/STATE21P IsC J ✓ v ��J'� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATEJZIP LICENSE b6-57 1 1 C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section_ INTENDED USE Domestic/Private _ rogation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization - Public Water System If different from Owner: Water System ame Contact Name or Phone Number TYPE OF WORK � ew Well ❑ Replacement Well ❑ Well Alteration/Modification s Other Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings Out-Of-Service Well ❑ Out-Of-Service Well Renewal s Cross-Connection Repair �I4ew Pum ❑ Pump Replacement n Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method>(Oud Rotary ❑ Air Rotary 1t Auger ❑ Cable Tool a Push Point I I Other Proposed Well Depth? 0:> ' it Excavation in diameter �_i Open Bottom ,Nts Gravel Pack/Gravel Size in diameter Conduc r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched�2 .2,Z ❑ Steel Plastic Stai Gss Steel n Other Grout Seal Depth? '� ft Neat Cement(94 Ib bag/5-10 gal water) 56and Cement; 'T sack m/x/7 gal water Bentonite(20%solids) '1 Other Grout Placement Method dumped Free Fall n Other 1-1 Retardant/Accelerator(name) PEDESTAL Installed By >15riller o Pump Contractor G Other Il Concrete Pedestal I_iDimensions:Width it Length it Thick in ❑ Christy Box Stove Pipe i PUMP O<Submersibleo Turbine ❑ Other HP V Pump Set it 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 THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M= M 2 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 ,aa� //� 'L SIGNED TITLE{y l�� ATEA�� V E VR A T D P R M DEPARTMENT USE ONLY Application Accepted By /�• AIAtO-tA Date t Ih_ Area ©O Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By _ Date Con truct d Well Depth It COMMENTS &Z 04rf4ildZ PE SC Received Check#/ Amount Permiv Codes Info B It Cash Remitted Date Service Re estInvoice# Well ID# 4&41 Kb I - r 1 14 6900 ll g9 4310 1 e2> S3- 1'4"t% Itl /96 EHD 43.06 WELL/PUMP PERMIT 4/30/12