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WELL/PUMP 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 u JOB ADDRESS "ti "l I ! ; '-,j,a i-�_ n u. - CITY/ZIP E CROSS STREET (�; {' ` iC r', APN 01-4-'- ��i-' -'i' L2 PARCEL SIZE +- % LAND USE APPLICATION# n OWNER NAME i.'E' 1(I .. i PHONE Y1 LI7 41.. OWNERADDRESS r�•� L� f "I 1� CITY/STATE/ZIP CONTRACTOR \ 'A t>t' +i �,• .I i' t :� 1 PHONE .-' CONTRACTOR ADDRESSf 1 �JG' S 3: �{ CITY/STATE/ZIP i ,�' I ><:)'^• 'I c "7 f SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATEIZIP LICENSE "trC-57 f7 C-61 1 D-09 ❑Other NUMBER t!'(:'�i✓i, .% EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USE a Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization D Public Water System It differer4 from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK In New Well U Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) I of borings ❑Geotechnical a of borings ❑Out-Of-Service Well U Out-Of-Service Well Renewal ❑Cross-Connection Repair Il New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method 11,Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool U Push Point ❑ Other Proposed Well Depth ft Excavation In diameter ❑Open Bottom p Gravel Pack/Gravel Size in diameter D Conductor Casing In diameter / Conductor Casing Depth ft Well Casing Diameter In Thlckness/Gauge/ASTM Sched ❑Steel ❑*Plastic C Stainless Steel ❑Other Grout Seal Depth / it ❑Neat Cement(94 Ib bag/5-f0 gal water) ❑Sand Cement sack mix/7 gal water s Bentoni(e(20%solids) U Other Grout Placement Method LrPumped ❑Free Fall ❑Other ll Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller r; Pump Contractor ❑ Other n Concrete Pedestal[-Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe MP G SubmerslbleU Turbine t;Other HP Pump Set fl 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. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209^)y953-7697 SKi►ED ti TITLE I fF DATE /-. /i,-•_ l f I � � Ir IN Ot N E VI 301M EAUl pEPARTMENT USE ONLY Application Accepted By Date / l 'Ir Area ^�!) Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date�� Constructed Well Depth _ ft COMMENTS PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Caeh Remitted Service Request# •Doom W ELL/PUMP PERMIT