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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1� �""`�� G.L(iM�e/L <<ti/h C CITY/ZIP Lo % / (, L� D CROSS STREET /"lY Y �� APN O�J LI J� I PARCEL SIZE L J LAND USE APPLICATION# m fy 1 rr- `(;L`�IA \ PHONE cn OWNER NAME / 11 (.1 a > r _ OWNER ADDRESS iI)I +C� �l'1(�.Il—tr�S^('l`a --ter CITY/STATE/ZIP ttl/\ CONTRACTOR �Ll�,'r, I CtL' PHONE 1�1'I `r� CONTRACTOR ADDRESS �`-00, T: �^, J"il r pi"—i V- �k. ��I) CITY/STATE/ZIP �-t'17L'Lgl / �'T / � ) 7 b i" SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I l C-57 IJ C-61 U D-09 1.1 Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑ Domestic/Private i 1 Irrigation/Agricultural I I Industrial I I Water Quality Monitoring )�Soii Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK u New Well I-1 Replacement Well El Well Alteration/Modification !I Other ❑ Monitoring Well(s) #of wells CI Soil Boring(s) #of borings Geotechnical _#of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 11 Cross-Connection Repair ❑ New Pump LI Pump Replacement ❑ Pump Repair I Raise Well Casing WELL CONSTRUCTION Drilling Method a Mud Rotary ! Air Rotary I'll Auger I I Cable Tool I I Push Point i i Other I f ., , Proposed Well Depthi 0. SLS ft Excavation in diameter I Open Bottom I I Gravel Pack/Gravel Size in diameter I I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel I I Plastic I I Stainless Steel ii Other Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) I I Sand Cement sack mix17 gal water Bentonite(20%solids) 9thEtP'�u: wt i Grout Placement Method I I Pumped I I Free Fall ther I! Retardant/Accelerator(name) PEDESTAL Installed By I I Driller I I Pump Contractor I I Other 1-1 Concrete Pedestal Dimensions:Width ft Length ft Thick in I I Christy Box I-I Stove Pipe PUMP 1 Submersiblel I Turbine I I 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / 11 SIGNED\,�� . TITLE ('JeE�t— 0L/h.4, DATE / -- - -I-- - REP r 3 I - ::I.ghL141a.Ri --EEiphl Y�iR�. DEPARTMENT USE ONLY Application Accepted( y � � _ Date ,O Areae_ Employee ID# Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date71� WAIVER Received Soil Boring I pection By Date Constru ed Well Depth ft COMME v T`� 1 - PE a ve ec Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# to C, ; OL4 EHD 43-06 WELL/PUMP PERMIT 8/04108