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b • r r 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 2-1 co Lorrowe «P Crry0P T V l,- 5_ A 1 0 CROSS STREET 1 u 1 ApN DZ PARCEL SIZE ! LAND USE APPLI TION# a OWNER NAME fn 7— PHONE N OWNER ADDRESS vl V CITY/STATE/ZIP �J CONTRACTOR i»DO.04�IJJ[ O 10 00NTRACTOR ADDRESS PO �D �/(� PH�ON�E /6C4 yj J' q �j�l—r A1/ CITY/STATE/ZIP R I V`"�/r V Vl I� SUBCONTRACTOR I�I (/� PHONE SUBCONTRACTOR ADDRESS CITY(/ST(ATTErZIP ��( f` LICENSE C-57 L C-61 U D-09 U Other NUMBER —1 1 EXPIRATION DATE —1. ( �V GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ INTENDED USE XDomesticfPdvate 7 Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization U Public Water System Ifdifferent from Owner: Water ysem Name Contact Name or PhOM Number TYPE OF WORK X New Well L Replacement Well U Well Alteration/Modification • U Other �� • ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings O Geotechnical #of borings ECE1v En❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair U New Pump L Pump Replacement u Pump Repair U Raise Well Casing WELL CONSTRUCTION f4l IG 2014 Drilling Method)(Mud Rota C Air Rotary C Auger 7 Cable Tool ❑Push Point ❑ Other Proposed Well Depth ft Excavation_I-2 in diameter U Open Bottom U Gravel Pack/Gravel Size in dia AQUIN n Conduct r Casing in diameter NTY / Conductor Casing Depth ft HEAD ROMMENTAL Well Casing J)i�le�e in Thickness/Gauge/ASTM Sched,SQ� n Steel Plastic n Stainless Steel '1 Other Grout Seal G� ft C Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack m1x/7 gal water UEPARrMENr Bentonite(20%solids) L Other Grout Placement Method umped ❑Free Fall C Other 0 Retardant/Accelerator(name) PEDESTAL Installed By ]Driller C Pump Contractor ] Other ❑Concrete Pedestal❑Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible?Turbine C Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT 1 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 �MPENSATION LAWS. M UR ADVANCE NOTICE REQUIRED FOR t,INS�P,EECjTION i-.(PLEASE CALL(209)999 3-76 7 SIGNED TITLE lJ Vim+"-• I `�` DATE U EPARTMENT U E O LY Application Accepted By Date Area �� mployeeID# Grout Inspection By Rate ❑ SPECIAL Wd1 Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS �t� `r Y � 0 COQ PE SC Received Amount Permit/ Codes Info B Cash Remitted Date Service R,/•uest# Invoice# Well ID# - 6 r1 '/9OFC6�/i-`ir3� /J r� EHD 43-06 WELL/PUMP PERMIT 4/30112