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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 uA1E ISSUED JOB ADDRESS / !! / ( 2%�%% / /� �/ l / , f CITY/ZIP_�y� CROSS STREET — %� 4''//PN 0 � ��y I� PARCEL SIZE L,' LAND USE APPLICATION #7 OWNER NAME � FYI �L O / ! PHONE / 271—zl? �y OWNER ADDRESS �� y��/'f® CITY/STATE/ZIP GIl CONTRACTOR r � PPHONE !&/ i 72-, �p(J CONTRACTOR ADDRESS �I f CITY/STATE/ZIP_ b-211 hr"' SUBCONTRACTOR PHON SUBCONTRACTOR ADDRESS CITY/STATE/ZIP !�5 LICENSE 57 C-61 i) D-09 Other NUMBEREXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE �C Domestic/Private C.: Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization I l Public Water System If different from Owner: Water System Name------ C—ontact Name or Phone Number TYPE OF WORK n New Well L1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings U Geotechnical # of borings ❑ Out -Of -Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump /_VPUmD Replacement ❑ PumD Repair ❑ Raise Well Casino Drilling Method U Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool U Push Point U Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom L� Gravel Pack/Gravel Size in diameter U Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic C Stainless Steel ❑ Other Grout Seal Depth ft -1 Neat Cement (94 Ib bagl5-10 gal water) U Sand Cement sack mix/7 gal water I Bentonite (20% solids) '.1 Other Grout Placement Method 11 Pumped ❑ Free Fall (7j Other L Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller 7, Pump Contractor LI Other Concrete Pedestal i Dimensions: Width ft Length ft Thick in ❑ Christy Box n Stove Pipe PUMP A Submersible[ 1 Turbine 11 Other HP I Pump Sete_ It Standing Water Level 3 S- :t ft I 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 COMPENVJION LAWS, MI M UUR�ADVANCE NOTICE REQUIRED FOR INSPECT NS -PLEASE CALL (209) 953-7697 SIGNED y ` // l TITLE � DATE G -/- / !] Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS PARTMENT// USE'ONLY 'g--1 `' Date Date Date J Date Area 1 ,5 t �� ) Employee ID# td O SPECIAL Well Permit WAIVER Received Constructed Well Depth ft T D v 0 M M ur PE Codes Sc Info Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# y3� � asp �' � ►5 7 � � �•� EHD 43-06 WELL /PUMP PERMIT 4/30/12