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10 WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET- STOCKTON CA 95202 - (209) 468-3420 nAr r renes OC-1'7co'7 ono IuC-TInIUC FXPIRFS 1 YFAR FROM DATE ISSUED JOB ADDRESS ,Igo/��/OOp__ 77 Q�_ CrTY21P i6se- Ld OV, • S�7G� CROSS STREET ./ /L APN, /O{ 5/7- oa 40 'IGVARCEL SIZt 4. S�LAND USE APPLICATION # OWNER NAME / J 2� el /W /C i/w�^-S Ar- PHOJ� ,91 G99G/J- 3 OWNER ADDRESS //f �. t7� 4 L4- 12 eyAl 1��• CITY/STATEMP 404A</J/_'►QG)C�J^7GA CONTRACTOR / ll�A�%.L O�rV� /'VL• PHONE —V7/ J/J Z— CONTRACTOR ADDRESS %GB %ylOw'o CITY/STATEIZIP CA �" •+70 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE17JP LICENSE C-57 I C-61 I I D-09 I I Other NUMBER Y „2 _L_.�� EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Townshlp li Rangeal— Section -AL INTENDED USE ❑ Domestic/Private rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization ❑ Public Water System If different from Owner Water bystem Name L;ordact Nam or F one NUmber TYPE OF WORK New Well C Replacement Well ❑ Well AlterallondModification C Other sofbodngs [I Geotechnical /or boring. ❑ Monitoring Wells) # of wells 7 Soil Borings) ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pum ❑ Pump Replacement ❑ Pump Repair C Raise Well Casing WELL CONSTRUCTION Drilling Method A Mud Rotary ❑ Air Rotary ❑ Auger 7 Cable Tool 7 Push Point ❑ Other Proposed Well Depth 3" it Excavation t 0 In diameter 7 Open Bottom Gravel Pack/GTavel Size � �• in diameter I I Conductor Casing In diameter / Conductor Casing Depth ft ' Well Casing Diameter LL— In Thickness/Gauge/ASTM Sched S J71211 C Steel XPlastic C Stainless Steel -J Other Grout Seal Depth SD It 7 Neat Cement (J4llbbbbag/5-10 gaf water) / 7 Sand Cement sack mixt) gal water C Bentonite (20% solids) 31 7ther— Grout Placement Method 4pumped a Free Fall a Other u Retardant / Accelerator (name) PEDESTAL Installed By C Driller Pump Contractor ❑ Other ❑ Concrete Pedestal Dim sions: Width ft Length R Thick in C Christy Box C Stove Pipe PUMP ❑ SubmersibleC Turbine ❑ Other HP Pump Set ft Standing Water Level it I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DUNIE IN AL;UUnUAN" vvltn JAN 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 CO PENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICEf%RVQUIRED FOR INSPECTIONS SIGNED � TITLE �51DE/V DATE -7 / //^^�� DEPARTMENT USE ONLY Application Accepted ByXC-� Date 110C11 Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Dale COMMENTS_— fIl ED Area� 4� Employee ID#— ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft EHD 43-0e WELL /PUMP PERMIT 8/04/08