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WELUPUMP PERMIT L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1 /� cn -t� `� JOB ADDRESS { CITY/ZIP m a z o CROSSSTREET i J(A—P/N /JJy +1 PARCE.�L/SII,Z�E�(� LAND USE)APPPLIICATION# � I a OWNERNAME T�Wn I / I ` V LJ 1 l/�-Cn�J PHONEoC0f,77d-- --?,jj. I N OWNER ADDRESS ! ' 1 Fog �pgf�L'*` V1/� CITY/STATE21P CONTRACTOR y'^/�-15,■/��W tS { br� ` I I- 1 P•HLO�N! � to CONTRACTOR ADDRESS 1' C) VJSL 1 CITY/STATE/ZIP Q(y SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS ��y��CrIII+T��^-Y/�StT.AT�E/ZIP r� LICENSE C-57 L C-61 U D-09 U Other NUMBER`46 1q EXPIRATION DATE 1 I C' _ GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ _ INTENDED USE Domestic/Private 7 Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization U Public Water System If different from Owner Water ys em Name GontaCt Name or one um er TYPE OF WORK New Well L Replacement Well U Well AlteratioNModification U Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #ofbodngs ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair U New PUmp L Pump Replacement U Pump Repair Li Raise Well Casing WELL CONSTRUCTION Drilling Method X Mud Rotary C Air Rotary [:Auger 7 Cable Tool ❑Push Point ❑ Other Proposed Well Depth �y ft Excavation in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter Fl Condu or Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad 11 Steel R Plastic ❑Stainless Steel Other Grout Seal Depth ID ft C Neat Cement(941b bao-10gal water) ❑Sand Cement sack m/x/7 gal water '*Bentonite(20%solids) L Other Grout Placement Method Pumped ❑Free Fall C Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller C Pump Contractor D Other ❑Concrete Pedestal❑Dimensions:Width ft Length it Thick in ❑Christy Box ❑Stave Pipe PUMP ❑Submersible?Turbine C Other HP Pump Set ft 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 COMPENSATION LAWS. N( II JM 24 HO R NONICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953-7697 SIGNED TITLE—C/ I�-' /rj(� DATE � FI VFX 1 7 2018Nr �jjjV Co IFp TY MEN' A , MENT US� ONLY / t Application Accepted By ) Date Area Employee ID# W /meq f• i Grout Inspection By �(U. ��m� Date11 ❑ SPECIAL Well Permit Pump Inspection By�� Data ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth it COMMENTS PE Sc Received Check#/ Amount Date Permit/ Invoice# WeIIID# Codes Info B Cash Remitted Service Request# EHD 43-06 WELL/PUMP PERMIT 4/30112