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ARTMENT USE ONLY Date 47/0/1112___ -1,sk 5(itA t 40 -16 oco" WELL/PUMP 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 \1--) N ( -\ 1)kCA 4 A . CITY/ZIP" e i t y ...' C ) 5 ,.. CROSS STREET 1(''\ L,4 B1 APINI .-)klq - C)LIL--C 1 PARCEL SIZE 1 -j 3 LAND USE APPLICATION # OWNER NAME L, 1 - rt" i y .b TO ii? 1- 1.._ CI, pHoNE) D Q 5 •-P -)1 i 1CA1 fi -C\;) OWNER ADDRESS. --3-.);) P1- L4 Ct..-k-/\ kV rni6 f PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 '1 C-61 D-09 [1 Other D NUMBER A2.2 Li EXPIRATION DATE 2 GEOGRAPHICAL INFORMATION: Coordinates X Township Range Section CONTRACTOR CONTRACTOR ADDRESS ( I 3o ry ,P (Ali d1:t/iti-zawsTATEmp _Pk,(je it")-11 ei e'1V SUBCONTRACTOR CITY/STATE/ZIP 11 1 )i i÷y 111q51 PHONE C)/(2). - 1-)61/2°),67) :SS3b1ClaV 311S INTENDED USE Domestic/Private n Irrigation/Agricultural n Industrial I Water Quality Monitoring U Soil Sampling/Characterization ! Public Water System If different from Owner: Water System Name ContaciName or Phone Number TYPE OF WORK n New Well H Replacement Well LT! Monitoring Well(s) # of wells Out-Of-Service Well !! New Pump r: Pump Replacement Well Alteration/Modification [1 Other 0 Soil Boring(s) # of borings Geotechnical # of borings Out-Of-Service Well Renewal 0 Cross-Connection Repair Pump Repair n Raise Well Casing WELL CONSTRUCTION Drilling Method Li Mud Rotary Air Rotary H Auger LI Cable Tool 111 Push Point Ill Other Proposed Well Depth ft Excavation in diameter Open Bottom n Gravel Pack/Gravel Size in diameter Well Casing LI Conductor easing Diameter LO in Thickness/Gauge/ASTM Sched in diameter / Conductor Casing Depth ft Steel LI Plastic n, Stainless Steel Ti Other Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) _1 Sand Cement sack mix17 gal water 1 ! Bentonite (20% solids) !I Other Grout Placement Method 1 Pumped Free Fall Other Retardant / Accelerator (name) PEDESTAL Installed By [_1 Driller II Pump Contractor Li Other Concrete Pedestal Dimensions: Width ft Length ft Thick in :t Christy Box n Stove Pipe PUMP Submersible r! Turbine ! Other HP Pump Set ft Standing Water Level ft I HEREBY CE JOAQUIN COU CURRENT AN WORKERS CO TIFY HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN TY 0 DINA CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS ACTI E WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL PENSA ION LA S. DVANCE NOTICE REQUIRED F,C1 INSPECTIOr. PLEASE CALL (209) 9 3-7697 TITLE ) e-.T14-2,6 t DATE C- icSIGNED MINI UR 7706~ U,. t - -1r • c4f00 V d`s, 16 1 0 .). ' -..'Li 4/V JOA ? 016 //: L- 41 rion A enti 1-1 i r)r -7 •Ervt. P ri /It lir Area c/44 Employee ID#A SPECIAL Well Permit L WAIVER Received Constructed Well Depth ft Application Accepted Bys-- Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS PE Codes SC Info Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 4-v-f- ii 8 de /;s- ,lii( 6° liolio sK.DO -75-Lii 4 1 h. , r- EHD 43-06 4/30/12 017 WELL /PUMP PERMIT