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' WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 M NON-REFUNDABLE PERMIT JOB ADDRESS It IJ CROSS STREE OWNER NAME Wrvm' OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRAXC-57 ADDRESS LICENSE r 1 C-61 ,I D-09 n Other 953-lb9/ FOR INSPEGIIUNs 1 1 CHn rnvm vr�ia wvvw 0_ CITY/ZIP (10m_ 15 V I PARCEL SIZE LAND USE APPLICATION ## PHONFi/ q :q )E *q mb1 NUMBER CITY/ST PHONE�1 %�[J�/ Q�y CITY/STATE/ZIP (qPHV�(J ( / / /6:-.r—s PHONE CITY/STATE/ZIP EXPIRATION DATE GEOGRAPHICAL I O,JRMATION: Coordinates X Y Township Range section INTENDED USE' Domestic/Private [ Irrigation/Agricultural U Industrial ,_ Water Quality Monitoring U Soil Sampling/Characterization t I Public Water System If different from Owner: Water System Name------- Co_ntact Name or Phone Number TYPE OF WORK ❑ New Well [ 1 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑ Out -Of -Service II U Out -Of -Service Well Renewal ❑ Cross -Connection Repair F1 New Pum Pum Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger Li Cable Tool U Push Point ❑ Other Proposed Well Depth ft Excavation in diameter '] Open Bottom [I Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth it Well Casing Diameter in Thickness/Gauge/ASTM Sched iJ Steel CI Plastic U, Stainless Steel ❑Other Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water CI Bentonite (20% solids) I 1 Other Grout Placement Method L1 Pumped -1 Free Fall 7, Other f' Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller :1 Pump Contractor ❑ Other n Concrete Pedestal F. Dimensions: Width ft Length ft Thick in ❑ Christy Box f1 Stove Pipe PUMP Submersible[! Turbine I ; Other HP= Pump Set ft Standing Water Level El. E 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 COMPEN ION LAWS. NIMU R CE TICE REQUIRED FO INSPEC S - PLEASE CALL (209) 9 - SIGNED l � /�� 1(/Y� TITLEIY IlH'�YW— , DATE EP RTMENTS ONLY Application Accepted By Date 77 Grout Inspection By Date Pump Inspection By Date io �4 Soil Boring Inspection By Date COMMENTS Area Employee ID# 41 SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft to n v 0 n m N PE qoqRs Sc Info Received By Check*--) Amount Remitted Date Permit/ Service Request # Invoice # Well ID# l /_> S -712,110 OU 05U EHD 43-06 4/30/12 WELL /PUMP PERMIT