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`. Ky- WELUPUMP PERMIT SAN JOAQUIN 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 m m JOB ADDRESS Ot f °t y C ' ` r ' '1 CITY/ZIP — D CROSS STREET L?1! APN L 04,L, PARCEL SIZE LAND USE APPLICATION# m Cn OWNER NAME — LJ4 ✓`art/ -JI S PHONE QtG J�`r N r l OWNER ADDRESS j j2_i1 CITY/STATE/ZIP 1 / r ' CONTRACTOR / (►Q rJ��y/':')� L/✓I1�1 I l-1 q PHONE CONTRACTOR ADDRESS Y 1 �i .`T r/!� a' ( ��t CITY/STATE/ZIP /�P � d�1 r- SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 'I C-57 'I C-61 '1 D-09 11 Other NUMBER EXPIRATION DATE ? n GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE U Domestic/Private C Irrigation/Agricultural U Industrial ❑ Water Quality Monitoring u Soil Sampling/Characterization 11 Public Water System If different from Owner: Water System Name onfact Name or Phone Number TYPE OF WORK ❑ New Well l l Replacement Well ❑ Well Alteration/Modification ❑ Other i7 Monitoring Wells) #of wells ❑ Soil Boring(s) 11 of borings L Geotechnical If of borings ❑ Out-Of-Service Well U Out-Of-Service Well Renewal U Cross-Connection Repair i New Pump Pump Replacement U Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method U Mud Rotary 0 Air Rotary i; Auger U Cable Tool 1 Push Point ❑ Other Proposed Well Depth ft Excavation /, in diameter D Open Bottom I-! Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 'i Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 24 ft Neat Cement(94 Ib bag/5-10 gal water) a Sand Cement sack mix/7 gal water f I Bentonite(20%solids) `1 Other Grout Placement Method U Pumped _1 Free Fall C Other ' Retardant/Accelerator(name) PEDESTAL Installed By E Driller .7 Pump Contractor ] Other 1� Concrete Pedestal i Dimensions:Width ft Length ft Thick in L Christy Box 71 Stove Pipe PUMP r! Submersible[! Turbine i! Other HP Pump Set ft Standing Water Level It 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(209)953-7697 SIGNED TITLE `� 1`�Y DATE r:. a Yt l `J i c Q N O f L H 1 7 L FM 7 / DEPARTMENT USE ONLY Application Accepted By ` ( �/(% �f`-- Date_L� /�_ Area Employee lD# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By _ Date ❑ WAIVER Received Soil Boring Inspection By Date -� Constructed Well Depth It COMMENTS r PE Sc Received Check#/, Amount Permit/ Codes Info B CAS t{f Remitted Date Service Request#WA Invoice# Well ID# '7 EHD 43.06 WELL/PUMP PERMIT 4/30/12