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1 Vtc I ' WELL/PUIVIP 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 E PIRES 1 YEAR FROM DATE ISSUED rr sal/ m JOB ADDRESS I � � E �"��'� �� CITY/ZIP t +r! ! � "' D J - � / I bo CROSS STREET C 1_T0�` APN O V .PARCEL SIZE LAND USE APPLICATION# m OWNER NAME ��1\ V`'�4- - PHONE OWNER ADDRESS t C� r f 1 VIC-, r _ __ CITY/STATE/ZIP A l t CONTRACTOR A v PHONE o �n�_►I 2}l—� _ CONTRACTOR ADDRESS + �l CITY/STATE/ZIP 5+" SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 C-61 D-09 F Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE XDomestic/Private Irrigation/Agricultural Industrial -1 Water Quality Monitoring Soil Sampling/Characterization Public WaterSystem 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) It of wells ❑ Soil Boring(s) If of borings I Geotechnical_ n of borings ❑ Out-Of-Service Well fl Out-Of-Service Well Renewal Cross-Connection Repair n New Pump Pump Replacement YPurnp Repair Raise Well Casing WELL CONSTRUCTION Drilling Method .J Mud Rotary Air Rotary Auger Cable Tool Push Point Other Proposed Well Depth ft Excavation in diameter L Open Bottom Gravel Pack/Gravel Size in diameter '- Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 11 Steel ❑ Plastic Stainless Steel Other Grout Seal Depth ft I Neat Cement(94 lb bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) I i Other Grout Placement Method I Pumped P 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 X Submersible Turbine Other HP ) Pump Set ' -f 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 CO ATI LAWS. IIMUM C CE REQUIRED FOR INSPE'C'TIONS- PLEASE CALL(209)r;,3?717� SIGNED TITLE __ / �l-� DATE v� V E Jill2 HEA TH DEPARTMENT DEPARTMENT U E NLY Application Accepted By �.(Y/moi Date _ _ Area "G Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By ri '.yI r.1-, l� Lj, Date I 11-1 i'l(la ❑ WAIVER Received Soil Boring Inspection By Date _ Constructed Well Depth ft COMMENTS _— PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# EHD 43-06 WELL/PUMP PERMIT 4/30/12