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f/ art/ S IU�UL% -T- 3 e 3e WELUPUMP PERMIT SNN JOA06',N 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 _ r_n M JOB ADDRESS G� ? 1� ��_1-� 1zJ CITY/Zip CROSS STREETL f�Vl APN Z3 110 -!/ Y PARCEL SIZ@ /J LAND USE APPLICATION# m -- — —... — I N OWNER NAME C�,� rV jb� t ____ _ PHONE 5 OWNER ADDRESS 2 so' Nr. I,el - 12-d _ CITY/STATE/ZIP---_ ry, ��- Y / C�d CONTRACTOR1161�- C' _ PHONE CONTRACTOR ADDRESS � C1 A 1++btu i �/��J_�Z d CITY/STATE/ZIP /"I'[a r�`FS/ G. Ile:I CIS SUBCONTRACTOR _ PHONE SUBCONTRACTOR ADDRESS �CITY/STATE/ZIP 1 -7 LICENSE C-57 'I C-61 ;I D-09 n Other NUMBER ILJ��i ? �1 q_ I � �_ C:L-.. EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range___ Section_._..__. INTENDED USE ,ST Domestic/Private Irrigation/Agricultural U Industrial -i Water Quality Monitoring U Soil Sampling/Characterization 1 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK">(New Well I1 Replacement Well U Well Alteration/Modification CI Other IJ Monitoring Well(s) #of wells ❑ Soil Boring(s) __ #of borings I_ Geotechnical u of borings Cl Out-Of-Service Well U Out-Of-Service Well Renewal I] Cross-Connection Repair I' New Pump Pump Replacement ❑ Pump Repair J Raise Well Casing WELL CONSTRUCTION Drilling Method>dMud Rotary ❑ Air Rotary Auger a Cable Tool I Push Point ❑ Other Proposed Well Depth 3 C3G� ft Excavation � in diameter J Open Bottom -)Gravel Pack/Gravel Size��_ in diameter Ll Conduc Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched t 0 --I _] Steel ;K Plastic ❑ Stainless Steel CI Other Grout Seal Depth �! _ ft Neat Cement(94 Ib bag/5-10 ga!water) a Sand Cement sack mix/7 gal water 7Q Bentonite(20%solids) I] Other Grout Placement Method Pumped Free Fall C Other Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 'YPump Contractor Ll Other Concrete Pedestal I Dimensions:Width ft Length ft Thick in Christy Box 1 Stove Pipe PUMP h Submersiblel' Turbine Other HP Pump Set It 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. MIN LUW 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 953-7697 / SIGNED r}fes i�J -' _. TITLE �s I�✓�� ; _ DATE - y n y •� 1 ,v �7 /f_ D Ej PARTMENTSEONLY EHT Application Accepted B Date 14711, Area Employee ID#��' Grout Inspection B ' cam- Date L / ❑ PECIAL Well Permit Pump Inspection By ��' ,.- Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received hecky Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# Yo zas"15 / '12, ,iD 43-06 WELL/PUMP PERMIT 4/30/12