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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 304 E WEBER AVE 3i°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 3 YEAR FROM DATE ISSUED /�]D�J� 76- cY L7 t,lJ` r-(( - L T (/'`� m („071'r17N. � lS lGV1+L S:':3 JYJ T3�iS� QAh V O G 4t 4"� �^" CpkpITY/ZIP 1 iLp p+ot�. SS S r -a c1- 3 7 q� I a CROSS STREET t cs a 1�'� o., Rwv I-L_APN 0&!( 030 -?,5 PARCEL SIZE �a �2MANDUSEAPPLICATION# V Q�� /d1 s �a►�) `tsr;.-s�s�Q OWNERNAME PHONE G - .>-• OWNER ADDRESSCITY/STATE/ZIP J CONTRACTOR �•�ts�� PHONE��'S) 3�3^ SSOO CONTRACTOR ADDRESS �� TiOw1� CITY//SSTATE1/ZIP MAv k� t C� Cj L+ I SUBCONTRACTOR c,-FGS CP- 4, �K.,)'C2S-te.w�-T ',wv:, kwK1 'KC�l� PHONE (ca. � LL 'g- L'3�- SUBCONTRACTOR ADDRESS ` "`^'"`i 1 CITY/STATE/ZIP 'd C- g 4 c3� LICENSE XC-57 ❑C-61 ❑D-09 ❑Other NUMBER L�b5 f (-S EXPIRATION':DATE GEOGRAPHICAL INFORMATION: Coordinates X -��l•53�R$2- Y -j2>' 0110 QA a - Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring oil Sampling/Characterization ❑Publie Water Syystem I I If different Ir. wner, Water System Name Contact Name or Phone Number I ' TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification. ❑Other I,� .# El Monitoring Well(s) #!of wells 13 Soil Boring(s) of borings [Geotechnical��#of borings I _ } ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ckrs `V^ ❑New Pum OPurnp Replacement ❑Pump Repair 1 WELL CONSTRUCTION Drilling Method' ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other .Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched, ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seat Depth (QO tt I Neat Cement(94 1i bag/5=10 ga!water) ❑Sand Cement sack mix l7 gal water ❑Bentonite(20%solids) /❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method A Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) n PEDESTAL 'Installed By ❑Driller ❑Pump Contractor El Other ❑Concrete Pedestal Dimensions:Width ft Length ' ft Thick in ❑Christy Box ❑Stove Pipe Pt1MP ❑Submersible ❑Turbine ❑Other HP- Pump Set ft Standing Water Level tt s I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN' i 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 I WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED / TITLE � &712h1•� -DATE r ® � 1 .i DEPARTMENT USE ONLY Y Application Accepted By 2�1Date Area �EC�fyee ID# J�r7 g 4iffawill(pection By r^ Date % © SPE IAL W;1 eLrrm1t Pump Inspection By Date © WAE`R>dteIt" Constructed Well Depth ft SAN 110AQU' C I COMMENTS - /,��j lt� G :/ - _ PE SC Received Chw1dWAmount Date Permftl Invoice# Well I )# Codes Info By Cash Remitted Service Re uest# 4+3•'7 15;-C) A- 11 y 13 0? 4 EHD 43-62-W5 /�� s�0_ `�.-�$ I - WELL PUMP PERMIT lmczoos ' I