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WELL/PUMP PERMIT SAN JOAQUIN COUNTI'ENVIRONMENTAL HEALTH DEPARTMENT 304 E WERER AVE 3"FL-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PEEWMJ�IIT �)1 ��(��/]/ CALL 209(953:7697 533-761911�7�sGfF1�OR INSPECTIONS EXPIRES 1 YEAR FROM /7XDATE ISSUED JODAUDRESS fly ___ - ��r ! - -• I CITY/ZIP mCROSS STREET ty Ra APN� / 'r_O O_K�PARCEL SIZE LAND USE APPLICATION ll_ /p. OWNER NAME Jt/1 OWNER ADDRESS cDID�OIGL� (,. �,(/� Clh'/SI'ATFIZIP Pip J. CONTRACTOR cLTI ^,J1r��r+��1T rF-/-�n/�u� (/L/cf�{- -��trlP /P'H`.OIN�E�a (// /Y CONTRACTOR ADDRESS I I-O-e - k•//C•' `�w'�1y�� Cn v/SrATEt7aP.�7��np C� �` ��/ SUBCONTRACTOR _ __ __ PHONE SUBCONTHACTORADDRFSS_ - __ CITv/STATEMP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EM52 tS EXPIRATION DATE. GEOGRAPIIICAI,INFORMATION: Coordinates X Y Township_ Range Section_ INTENDED USE Domcstic/Private ❑Irrigation/Agricultural ❑Industrial ❑Watcr Quality Mgnitoring ❑Soil Samp1mg/Charaetenzation Pi(PublicWater System :5&WV1e1f s(o'9'T7ot1' r C0/r1csjT'e 'Jr/VD�R rAPEFT �'0l'Sl/4L. If diRernr from Ormer. �ttem ante Henan Nme or Dae ul�� TYPE OP WORK Qi New Well ❑Replacenn:nt Wcll ❑Well Alteration/Modification 13Other np ❑Monitoring Well($) #of wells ❑Soil Boring(s) a of Da np ❑Geotechnical r o:bo ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replaccmcnt ❑Pump Repair W ELL CONSTRUCTION Drilling Method P(Mud Rotary ❑Air Kotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 1000 B Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sire in diameter 4 L t�e�e•Mlelx�❑Conductor Casing_ in diameter / Conductor Casing Depth___ ft Well Casing Diameter_in ThicknesslGaugc/ASTM Sehed /3oCnx Steel ❑Plastic ❑Stainless Steel ❑Other O Cron(Seal Depth JCL)V It WNcat Cement(941b bag/5-10gal water) ❑Sand Cement_____ sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name - ❑Specs on File ❑Specs Submitted .Grout Placement Method BPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PE.DF+'TAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width B Length R Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Othcr HP Pump Set R Standing Water Lcvel ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN -1✓ JOAQIIIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS. 1 AISO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED ! TITh /�-� 1��^"'� DATE HE HIVEld JPDE 2 w u P /^L PARTMENT USE ONLY Application Accepted By�_� - Date Arca___- _._ Employee lDN Grtut Inspection By _ _ Date ❑ SPECIAL Well Permit Pump Inspection By ❑ WAIVER Received Constructed Well Depth a t'�' ✓��- ""' - -/ n � M 11- CD3_ A*t /S SC eceved heck/ Amount Date PermlU Invoice •WeIIIDN Codes Info B Cash Remitted Service Request N