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WELL..-,UMP PERMIT .s ; SAN JOAQUIN COUNTY ENYIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE 31e FL-STOCKTON CA 45202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED rn `I JOBADDRESS I+ 12G31� N1ar�-�� CALlFG2Nllq ST'f��G{f CITr/zlP 5� rON ' CROSS STREET'�6r>T) PI W;E �/ /� APN PARCEL SIZE LAND USE APPLICATION OWNER NAME jll1 _H_Gu ([j }H/t ln��Uj_�N _ CPHO E_�� [. OtvNERADDREIISS �8 J•S !'�tC)r�.-L�(y � �(Q CITYISTATE2iP 7[4 �.To•) GA 45 [ CONTRACTOR11 P&CT"'rM IL�C.�/+�7ltx,.lh/ytsrElZ dNG� /r /�/y//� PHn E '71(a -7-7,7!1-7,7!1 CONTRACTOR �/ADDRESS T)H (J [ ZI D G_ Ay CITYISTATEIZIP 6L6P(- 64 ') S PES 2 u P V4 It PLO jZ a—cI o N I N c PHONE las� e 7 t z SIiBCONTRAC7OR Q� � SUBCONTRACTOR ADDRESS J sp S ✓�I�G mrd i'�'C rJ�I't/G CITY/STATE/ZIP ��O 7B1V 64 11520-5 LICENSE -57 ❑C-61 00-09 Q Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USE XI E7 Irrigation/AgricURUTal ❑Industrial ❑Water Quality Monitoring ❑Soil Sampting/Characteriralion ❑Public Water System w onr um ar if diAerent from Ownen ater yslem arae onlac[N. TYPE OF WORK ❑New Well 13 Replacement Well 0 Well Alteration/Modification Cl Other #orborings II ❑Monitoring Well(s) N ofwells ❑Soil Boring #of boring Boring(s) s ❑ eotechnical I� )Kout-Of-Service Well ❑Out-OFService Well Renewal ❑Cross-Connection R epair C1 New Pump Q Pump Replacement ❑Pump Repair W ELL CONSTRUCTION Drilling Method ❑Mud Rota/ry ❑Air Rotary ❑Auger 0 Cable Tool ❑Push Point 13lher X i Weil Depth �a r0 R Excavation in diameter ❑Open Bottom ❑Gravel Pack l Gravel Size in diameter iU Conductor Casing in diameter / Conductor Casing Depth n Well Casing Diameter�in Thickness/GaugelASTM Sched STt7 APIC J(Steet o Plastic ❑Stainl ms Steel ❑Other Grout Seal Depth.__ n Neat Cement(94 lb bag/S-10 gal water) ❑Sand Cement rack mix!7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method Pumped ❑Free Fall ❑Other D Retardant I Accelerator(name) PEDESTAL I� Installed By ❑Driller ❑Pump Contractor ❑ Other Ll Concrete Pedestal Dimenslons,Width D Length h Thick in CI Christy Box ❑Stove Pipe PUMP II ❑Submemilhle ❑Turbine ❑Other HP Pump Set n Standing Water Levcl n I NERERY CERTIFY THAT!HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILT,-BED NE IN ACCORDANCE WITH SAN IOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY IIIAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. nAI IN MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC IONS SIGNED /%GGA � � - --- TrTLE�1V1i C-"4 1v � DATE /G��0, N101671U 6 C MW#ti&; esrrc cz P/L < n ry PROPEJ OWNED BY OTHERS� PINE STREET II DEPARTMENT USF ONLY - Applicann A epted By Date [ Area Employee IDN Grout Inspection By slate , E7 SP CIALWeII Permit a Pump Inspection By Dale � W IVER ReCelVetl Constructed yWyell Depth ft COMMENTS II PE SC Received Checkfll Amount Permit! Codes Info R Cash Remitted Date Service Request# Invoke M Well[DM AAA- 0�5 Do —!5f a o 4 FILE COP'S WELL PUMP PERMIT 'n n°}°'Z°°b i ENMnONMENT.HEALTH PERMIT/SERVICES