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Zri-C"\ 5c" I,,—n—(4 0 ^ WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 Wq,5fbN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED O`er r J09 ADDRESS !�! � � tl�fO Age, CITY21Pl.Sn_��t/ y CROSS STREET C,."A,i V?.t t 9. �A�V_APN Z�11 —1 50"W PARCEL SIZE o3 LAND USE APPLICATON# m (we y�/� 7, N OWNER NAME l�� a \`^` to f?4-; 0 `I A PHONE( 05� t� `'� OWNER ADDRESS 1 ('� J� ,. j �yQ" ^� + �k{'e. CITY/STATE2ip Q-s c/ loon,`, �j� -15 � /2D CONTRACTOR ( L��r'ih�S(-0061 ,a °2- PHONE\/ 1 D C,-71-5'Ll 1 Ps 43 CONTRACTOR ADDRESS go,• n!& t 1 ` CITY/STATE/ZIP t CCS. -I -7 SUBCONTRACTOR ^4JIA PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE KC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER- 92& I— EXPIRATION DATE - / GEOGRAPHICAL INFORMATION: Coordinates X Y Township— Range Section_ INTENDED USE /DomeSliC/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization 11 Public Water System If di#erent from Owner; Water System Name Contact Name or one Numb TYPE OF WORK /New Well XReplacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) If of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair UUT 14 2016 ❑ New Pump o Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION ENVICOUNTY Drilling Method KMud Rotary ❑ Air Rotary Ji Auger ❑ Cable Tool L) Push Point E] Other HEALTHPOppa o,T.AL Proposed Well Depth�2.7 0cavation I VA in diameter 1: Open Bottom )Gravel Pack/Gravel Sizey�in diameter ❑ Conductor Casing IIYY in diameter / Conductor Casing Depth ft Well Casing Diameter_L in Thickness/Gauge/ASTM Schad 3&V— ❑ Steel Ff Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth-1!—QP l L I ' Neat Cement(94 Ib bag/5-10 gal water) 'Sand Cement 112iGa..e�. sack mix/7 gal water El Bentonite(20%solid Other 2Pcr� Se j I pASLyR.K1./ Grout Placement Method jWPumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Jy Pump Contractor ❑ Other Concrete Pedestal❑Dimensions:Width It Length it Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine (; Other HP Pump Set If 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 CALIFO NIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATI AWS. MIN 2 OUR A A E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE ©Ca V,2*1- DATE l�-LZ—ICn (� V 5 I 1 Z $ 3b t f;5 S ?I 1 81 9� tot S 1,12,0 tSa C- lb" G 1�� 5 t')A 5 1$ ► S 11S c Zdu 233 2,t+L LPARTMENT USE ONLY t Application Accepted D Dale o Area�_I Qq Employee ID#/"—Uw Grout Inspection Date El SPECIAL Well Permit I Pump Inspection 8y Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS0 S tG D PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 00 ) 0W Im sl2ob�l�o l c� 3� u EHD 43-06 WELL/PUMP PERMIT 4/3di2