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WELL -UW PERMT 1400 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT *111111w 304 E WEBER AVE 3R°Ft,-STOCKTON CA 952(I,%sa`14)468.3420 NON-REFUNDABLE PERMIT CALL 204 453-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS rC`SQD CrrYIZIP A v �J/JO�d� v CROSS STREET APN OOC � PARCELSIZE Colt LANDUSEAPPLICATIOK# 0"ERNAME hg,—Iq A /.�rt� PHONE /7 �+ OWNER ADDRESS I I 1'e(-y7 CITYISTATE ZlP ` ` J /` t CONTRACTOR //,/�/�y` U�] PHONE J369177 J, /y CONTRACTOR ADDRESS Q / 1fJir /Oma.- C1TYISTATE/ZIP�all `,--r s SDBCONIVACTOR PRONE StISCONTRACTOR ADDRESS CITYISTATFJZIP LICENSE C-57 XCfil E3 D-O9 Q Other NUMBER a� EXPIRATION DATE vO GEOGRAPHICALINFORMATION: Coordinates X Y Township_ Range Section INTENDED Us£ )f Domcstie/private ❑IrrigationlAgricultural ❑Industrial ❑Water Quality Monitoring ❑Sail Sampling/Characterization _ ❑Public Water System Ifditi tBons Owner. Wfttv System Name Contwt Namsm Phons Numbw TYPE OF WORK 9New Well. ❑Replacement Well ❑Well AlteratioulModiflcation ❑Other ❑Monitoring Well(s) #of welts ❑Soil Boring(s) a orborinas O Geotechnical a ofl,orirtgs ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Crass-Connection Repair ;IfNcw Rump ❑Plump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method XMud Rotary ❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point ❑Other Proposed Well Depth a[9b ft Excavation_/j2 I' _in diameter ❑Open Bottom Aravel Pack/Gravel Size %,Y in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft. -0 Well Casing Diameter iV in ThickaeWGaurJASTM Sched CA O Stect prPlastic ❑Stainless Steel ❑Other Q Grout Seat Depth^/00' ft 13 Neat Cement(94 Ib bag/S-IO gal water) )krSand Cement 103 sack mix 17 gal water � ❑Bentonite(206/6 solids) 13 Manufacturer Spec%solids % Name 0 Specs on File Q Specs Submitted a, Grout Placement Method Pumped ❑Free Fall O Other ❑Retardant/Accelerator(name) PEDESTAL Installed By WDnllcr Q Pump Contractor ❑ Other oncrele Pedestal Dimensions:Width ft Length fl Thick in ❑Christy Box O Stave Plpe PUMP nubmersible ❑Turbine 0 Other HP i' Pump Setft Standing Water Level ft I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. 1 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. MI [MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �p SIGNED 7/ TITLE PCes, DATE Y A v I M IN POP DEPARTMENT USE ONLY Application AcceptedB - Date �� Il b Area Employee ID# 5-3(0(0 UI Grout Inspection Date,• �'��✓�� 13SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Constructed Well Depth COMMENTS 13 L L c'T o F .424t—co,;?-,0 PE SC Received AmountDatPermit/ Invoice# WellID# Codes Info B e Cash Remitted Service Request# 6H- GSD S`o•6rJ END43-02-M WELL PUMP PERMIT MM00s