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�/a7c WELL/PUMP PERMIT ��"� I, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 9526i' 211 ) NON-REFUNDABLE PERMIT CALL 209 953-7697 OR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED jq �A 2r y JOB ADDRESS O V CITY, �� 3 CJ D CROSS STREET / \A) 'W` APNy��p J u)- PARCEL SIZE 1�LAND USE APPLICATION# m r Ili PHONE N OWNER NAME j f OWNER ADDRESS CITY/STATE/ZIP L-�( `J I�1 J lQ cc) 3� CONTRACTOR u V �Cv. - PHONE �J `tet ^/[J9t rN CONTRACTOR ADDRESS 4 i CITY/STATE/ZIP S6&,L� _ / )a9` SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 3V6 LtO EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water-System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing 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 Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft 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. ,,--�7MINIMUM OUR ADVANCE NOTICE R ED FOR INSPECTIONS SIGNED TITLE Y 1 DATE W/ ,p r% vralir- INE H H E T EN PA TMENT US N L Y Application Accepted By Date t Area Employee ID#— / Grout Inspection By Date II ` PECIAL Well Permit Pump Inspection By&%)1Jbft 5c t xn Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# P?b :W 2 �2 . I EHD 43-06 WELL/PUMP PERMIT 8/04/08