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�N1a1 SLwn `11?-Ib 0n WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS S CITY/ZIP C ' V ' ' D n CROSS STREET APN ( � . 2(`/r7 .XARCEL SRE�+�/ LAN USE APPLICATION# M m N iTL-//.CJ � � /�-/�-- P N OWNER NAME NE /� [�� /�� OWNER ADDRESS ` 7a N/A�-Gf771� � CITY/STATE/ZIP ��-�✓ g% • -+'•/`�/ CONTRACTOR PHONE CONTRACTOR ADDRESS 2i� �(A.0 G4�te Z?y I^, CITY/STATE/ZIP SUBCONTRACTORS PHONE SUBCONTRACTOR ADDRESS CITY/STATEJZIP 2` LICENSE -57 -61 n D-09 n Other NUMBER oI I�EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ ]MENDED USEomestic/Private U Irrigation/Agricultural ❑ Industrial CIWater Quality Monitoring U Soil Sampling/Characterization 4❑ Public Water System If different from Ovmer: Water System Name --------C-on-tac-1 game or Phone N u mbe r TYPE OF WORK lAew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Wells) If of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of bongs ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair JeAew Pump U Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONST TION Drilling Method [i Mud Rotaryf❑ Air Rotary ❑ Auger Ll Cable Tool U Push Point ❑ Other Proposed Well Depth �f ft Excavation /7— in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conductor asing in diameter / Conductor Casing Depth ft Well CasingDiameter In Thickness/Gauge/ASTM a/ASTM Schad 1_�ZG(U Steel ❑ Plastic ❑ Stainless Steel ❑ Other 9 / Grout Seal Depth 6 it 11 Neat Cement(94 lb bag/5.10 gal water) } and Cement /D�� sack mild7 gal water ❑ Bentonite(20%,solids) U Other Grout Placement Method umped ❑ Free Fall 11 Other I'!! Retardant/Accelerator(name) PEDESTAL Installed By ❑ Drillerump Contractor ❑ Other r, Concrete Pedestal i' mensions:Width It Length It Thick in ❑ Christy Box ❑ Stove Pipe PUMPubmersibleU Turbine ri Other HP 2. Pump Set it Standing Water Level ft I HEREBY CE TIFY 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 COMPEN ATION LAWS. MINI U CE NOTICE REQUIRED FOR IR�P,E�C/TIIONS- PLEASE CALL(209)9533776y9/77 SIGNED f , ��C_ TITLE Itil��-�— DATE--`� �-�-- 1 A U E T E H DEPARTMENT USE OY CO Application Accepted By Date a N Are. Employee ID# q" Grout Inspection By Date SPECIAL Well Perrnit Pump Inspection By Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth k COMMENTS ito!� 6 - fj /)-P PE SC Receiivv/ed Chheeck#/ Amount Date Permit/ Invoice# Well ID# Codes Into B Cash Remitted Service Request# q 4 3-7 `I ao 1 SAIX-7 �'3a 3 3 o 9 3 Ell 130 WELL/PUMP PERMIT Wiwi,