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u^� 1 5c& 1-},1- 17 O7 v-^ P d WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1860 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE IPERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos ADDRESS CITYIZIP m �4`ty`w�vC ( CIuT G' j Z CI � � p CROSS STREET t:t" APN Q y CI P3-0 a I PARCEL SIZE 7 Z,6 LAND USE APPLICATION# m N OWNER NAME GU Ifl - PHONE u, OWNER ADDRESS r ii yx ylLj a4ec Pl(.�c CITYISTATEIZIP `f7QA ,0 -)10.,1)t hCrn CONTRACTOR tit�rI i&— PHONE � (2,0C�J,O}AI�b –I;�)! CONTRACTOR ADDRESS -2 0 r Art," l"r)f ,,4 1`0 � ._V CITYISTATEIZIP �"Cklto i SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural r1 Industrial n Water Quality Monitoring Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name Contact ame or one um et TYPE OF WORK a New Well L1 Replacement Well n Well Alteration/Modification I I Other # 11 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings XGeotechnicalof borings F1 Out-Of-Service Well r1 Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump LI Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method n Mud Rotaryr I i Air Rotary )(Auger c❑�Cable Tool i I Push Point 11 Other Proposed Well Depth of-' ft Excavation 3 in diameter L1 Open Bottom 11 Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched -1 Steel 1_I Plastic 1:- Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-1 0 gal water) u Sand Cement sack mW7 gal water 1-1 Bentonite(20%solids) X Other SO1 1 C.wht&4� Grout Placement Method I I Pumped L7 Free Fall ❑ Other ❑ Retardant 1 Accelerator(name) PEDESTAL Installed By L Driller I I Pump Contractor ❑ Other Li Concrete Pedestal Dimensions:Width ft Length It Thick in ❑ Christy Box 1.1 Stove Pipe PUMP a Submersible F l Turbine ❑ Other HP Pump Set ft 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. i NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE Pv`eLt- 1 r' DATE ------------- l•'•3 E�- O 4 J LE'0X W, w-p DEPARTMENT USE ONLY Application Accepted �� Date Areae Employee ID# Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring I pection By Date Constructed Well Depth ft COMMENTS v sr PE SC Received Check#I Amount Date Permit! Invoice# Well ID# Codes Info By Cash Remitted Service Request OAC WELL!PUMP PERMIT EHD 43-06 8104!08