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' P WEL,UPUMP PERMIT SAN JOAOUIN 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 to f� Q / 't I l .� JOB ADDRESS i � 1� l s �l A t� A 1 I`r N I1ZQ CITY21P �.4 �� t Ga 5 320 D Q . �I CROSS STREET ,__kkSh LA.. APN 205-0q6 -Z10 PARCEL SIZE T• I LAND USE APPLICATION# m �3 -Z,S Yj N OWNER NAME ))LO .4 i S e (A S A 1.4r q IF0i0 /� PHONE U �j OWNER ADDRESS t (a1 Q c? S, L1,3Yt All red /�� CITY/STATE/ZIP AcScd lo'l CONTRACTOR 0 nse(I,,I 1 S O r,11 1r�'Tvv� PHONE CONTRACTOR ADDRESS —1 A 1 bet S 12 1 CITY/STATE/ZIP 1V1ddf IL U.�9 1c 5 1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 1 C-61 i I D-09 11 Other NUMBER b69 4 A I EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private P Irrigation/Agricultural ❑ Industrial L1 Water Quality Monitoring U Soil Sampling/Characterization I1 Public Water System It different from Owner: Water System Name Contact ame or P one um ber TYPE OF WORK KNeW Well I1 Replacement Well ❑ Well Alteration/Modification C! 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 Pum rl Pump Replacement ❑ Pump Repair 17 Raise Well Casing WELL CONSTRUCTION Drilling Method -9 Mud Rotary (I Air Rotary Ci Auger U Cable Tool U Push Point ❑ Other Proposed Well Depth 2U D ft Excavation /Z in diameter U Open Bottom X"Gravel Pack/Gravel Size_kL_in diameter U Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter JL in Thickness/Gauge/ASTM Sched�_ U Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth lG O ft I' Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) 1 Other Grout Placement Method YPumped i=1 Free Fall F Other 11 Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller Pump Contractor ❑ Other Concrete Pedestal F.Dimensions:Width ft Length ft Thick in D Christy Box n Stove Pipe PUMP F Submersible[; Turbine I; 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 COMPENSAIION LAWS. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 SIGNED TITLE -' >"'Ae-' DATE O) OL Pi N Vit r s S i _ AR PA ThI WHv a -ET 'TVENT CY \&S s Application Accepted By w Date Area Employee ID#F�w Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth COMMENTSAu"A PE SC Received h / Amount Permit/ Codes Info B Cash i d Date Service Request#EHD Invoice# Well ID# 06 WELL/PUMP PERMIT 4130112