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• WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL. 209 953-7697 roR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED O� -tom ADDRESS CITY/ZIP '��1 YL— Jos ^' Y APNCROSS STREET JLPARCEL SIZE _ LAND USE APPLICATION PPLICATION N OWNER NAME 4 PHONEJ �2` 3 6 T OWNERADDRESS •`11 CfTY/STATE/ZIP CONTRACTOR I J G IZE J`L nWOVIA L�� I`"G ,PHONE 71 CONTRACTOR ADDRESS rD V t 1`7 Q CITY/STATE/ZIP NJO SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY//STATE/ZIP LICENSE >77-57 ❑C-61 ❑D-09 ❑Other NumBEF�7 —1 of EXPIRATION DATE 07 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ji1.0omestic/Private ❑Irrigation/Agricultural Cl Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactenlation ❑Public Water System Ifdifferenrfrom Owner: mer ystem ame ontacr eme or orw um TYPE OF WORK ' dew Well Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) x ofbonnga ❑Geotechnical x of bonegs ❑Out-Of-Service Well ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair ew Purop ❑Plump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Dcpth ZRQ it ExcavationI"— in diameter ❑Open Bottom 1XIC.iravel Pack/Gravel Size in diameter ❑Conduct Casing in diameter / Conductor Casing Depth fl Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched%00 ❑Steel )Z[Plastic ❑Stainless Steel ❑Other Grout Seal Depth__�0(_ft ❑Neat Cement(941h Aug/5-10 gal water) Z0$and Cement /0.J sack mix/7 gal water w ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ,J24umpcd ❑Free Fall ❑Other ❑Retardant/Accelerator(name) _ PEDESTAL Installed By _,iiiiiII:yriller ❑Pump Contractor ❑ Other s.$Concrete Pedestal Dimensions:width n Length ft Thick in ❑Christy Box ❑Stove Pipe lm 34ulamersible ❑Turbine ❑Other HPPump Set n Standing Water Level ft 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE 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. M 24 HOUR ADVANCE.NOTICE REQUIRED FOR INSPECTIONS 3 slcneD �� TITLE (I AJAJ Ct- DATE G'Z3 F. -- P A R T M E N T U wE O L Y Application cc Date / Area Employee ID# L1//�r Grout Insi Date a ❑ SPECIAL Well PermitjPump InDate ❑ WAIVER Received Constructed Well pth \ ft �� O COMMENTS OI LI,., zo, t5 PE SC Received Checw Amount Date PermiU Invoice M Well IDM Codes Info B Cask- Remitted Service Request M _ q 7 f✓Pao a d