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X ' WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT 'CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED I �f� r JOB ADDRESS r 1V/� I CITYZP 1 �y 2 CROSS STREET w 7—,eCOdN /ct.� APN �.g—I7 —7S' PARCEL SIZE LAND USE APPLICATIONIlls #...777 OWNER NAME /I-�O PHONE C Xj/�� OWNER ADDRESS �'OI n J (5f�` CRYISTATE/ZIP �,e�/^ 4Y-��^�,A. CONTRACTOR WV r""�-' W PHONE (�.�1�/W/ �/—/f (/��/�c �j •� CONTRACTOR ADDREtU Ira 9-6 CITYISTATEIZIP�-�l/li� �7 I /'-�LJ 's SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CRY/STATEIZIP LICENSE 57 ❑C-61 0 0.09 O Other NUMBE�3� /f EXPIRATION DATE X L2 / GEOGRAPHICAL INFO ATION: Coordinates X Y Township_ Range Section_ INTENDED USE estic/Private G Ir igatlon/Agricultural ❑Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization ❑Public Water System .. If different horn Owner: water y m Nam uontact Name or Phone Nurnber TYPE OF WORK New Well 0 Replacement Well ❑Well Alteratlon/Modification 0 Other 0 Monitoring Well(S) #Of wells 0 Soil Boring(s) not borings 0 Geotechnical Pof borings ❑Out-Of-Service Well :]Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement 0 Pump Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method Vll l.d ❑ 'r Rotary 0 Auger 0 Cable Tool ❑Push Point Other Proposed Well Dep �— Excavation 1_In diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter pp� ❑C duct g in diameter / Conductor Casing Depth ft W Well Casing Diameter In hldmess/Gauge/ASTM Sched 2JX 0 Steel FSPlastic ❑Stainless Steel 0 Other Grout SealDe`pth . ❑Neat Cement(94/b bag/5-10 gal water) 0 Sand Cement sack m1x/7 gal water trrsen Ite(20° lids) ❑Other Grout Placement Meth umped 0 Free Fall 0 Other ❑Retardant/Accelerator(name) I[I PEDESTAL Installed By 0 Driller ump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width ft Length ft Thick In 0 Christy Box ❑Stowe PlpeyJA PUMP 0 Submerslblel]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. M=12 IOU_ DVANCE NOTICE REQUIRED FOR IN ECTIqbIS PLEASE CALL(209)95 -7 97 Z SIGNED TITLE DATE TTT r A E ;. r . ... :v s. ..�..._ FD F.p..A R.ZM_E TAU-S E O N L_Y Application Accepted By Date CO Area Employee ID# it Grout Inspection By ate D ❑ SPECUkL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspechon By Date structed Well D th ft COMMENTS LOF u-- S/ ,is F[.00 O i P£ Sc Received Amount Date Permit/ Codes Info B Cash Remitted Service Request# Invoice III Well IDS 34.6 r ko SS 19 :?LLI yl alaz �v o03 (6 1 EHD 43-06 6126109 WELL!PUMP PERMIT