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WELUPUMP PERMIT !SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PER IT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS /V? CITY/ZIP `V f ZT m - - D CROSS STREET(_ai 1 if APN I-10 r 44 PARCEL SIZE LAND USE APPLICATION# m A cn ou OWNER NAME _\ / /S�il-Ew, I ��' � �+ PHONE N OWNER ADDRESSt �7 � CITY/STATE21P ) CONTRACTOR � �f`0L�<' 'L ssF PHONES ` r ` �`S CONTRACTOR ADDRESS :/ " C 7o, CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE �C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 6 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE %ryDomestic/Private -� Irrigation/Agricultural G Industrial L, Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System If different from Owner: Water System Name ontact ame or hone um er TYPE OF WORK- New Well E Replacement Well ❑ Well Alteration/Modification ❑ Other u Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings � Geotechnical #of borings L! Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 'New Pump a Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method�Mud Rotary ❑ Air Rotary ❑ Auger. ❑ Cable Tool E Push Point ❑ Other Proposed Well Depth Q It Excavation ��yr in diameter J Open Bottom Caravel Pack/Gravel Size in diameter .-: Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 1?-- in Thickness/Gauge/ASTM Sched7—X) _ ❑ Steel Plastic ❑ Stainless$Leel ❑ Other Grout Seal Depth lls _ft _ Neat Cement(94 Ib bag/5-10 gal water) nd Cement sack mix/7 gal water Bentonite(20%solids) 2 Other Grout Placement Method 'Pumped C Free Fall ❑ Other Retardant/Accelerator(name) PEDESTAL Installed By -' Driller .'moi-Pump Contractor I L; Other Concrete Pedestal Dimensions:Width ft Length 3=ft Thick in 0 Christy Box E Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(20J9)DATE 953/<)—)3 -76971 SIGNED /+s$f ` �1,y�r%� TITLE a/ '�\ / `/<)r 13 ( r .1ye- �) i t n A yy ?--VP I - k Z ';, i U Ty DEPARTMENT USE ONLY i-IEALTH I)EPARTMEMT Application Accepted By,r 1 rav` i Date tof it 3 Area QI Employee ID#Cq l l 6cu;& Grout Inspectio ` Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMPENTS C A r-rod vlr4 ;,., r" PLobd 044) 1 PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Request# 4366 V0 i 4341 -" EHD 43-06 WELL/PUMP PERMIT 7/6/11