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WELL/PUMP FEMIT �Q ;.: 1E f . �77--i� • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CCC 95 -�(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 'I N M JOB ADDRESS 1 CITY/ZIP A [P). D CROSS STREET r T� APN y � � r PARCEL SIZL_?rlt,- LAND USE APPLICATION# m F In N L N OWNER NAMECA a PHONE CG OWNER ADDRESS 1` i 1. CITY/STATE/ZIP //J CONTRACTOR 11 U 14�r�' PHONE --710L 10? CONTRACTOR ADDRESS 1� __ CITY/STATE/ZIP wl 0 0 5 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE(ZIP C \I LICENSE C 57 C-61 D-09 -11 Other NUMBER EXPIRATION DATE b• GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE - Domestic/Private i-I Irrigation/Agricultural [_: Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization Public Water System If different from Owner: Water S e r= Nof Phone Number TYPE OF WORKNeW Well Replacement Well ❑ A era'o R,.i tin LAfr ff of borings ##O s T Monitoring Well(s) #of wells ,soil B ring(s), ppy �p �4tchnical__-� m �ItM1' Out-Of-Service Well Out-&-ax 1V�e �l� �[Ttft3t5Lepair F? ED New Pump Pump Replacement 7 Pune aieing R WELL CCNSTRUCTIO {�,I {{' � , ►�Q if Nn^I.�S5it/is`}�(1 PR 7 2015 Drilling Method r Mud Rotar� ❑ Air Rotary Auge• �al'�1yLb pv`r�'PMWA fY]`I�ther ` Proposed Well Depth ft Excavation _.in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel S� AL f IJi@Ifi•>yter =- Conductor Casing in diameter / Conductor Casing Depth ft HEArl QEPgR ENrWell Casing Diameter:in Thicknes auge/ASTMSched 0 u ❑ Steel Plastic ❑ Stainless Steel er Grout Seal Depth i , ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement d sack mbd7 gal water Bentonite(20%solids) Other Grout Placement Method !1 Pumped ❑ Free Fall Other �' Retardant/Accelerator(name) PEDESTAL Installed By DrillerPump Contractor Other F1Concrete Pedestal ❑Di ensions:Width ft Length ft Thick in - Christy Box Stove Pipe PUMP -i Submersible' Turbine I Other HP Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT I_ j_AVE PREP ED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORD.JNANCE�, ST) E L WS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH T�E CALIFOR IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSA?,ION LAW `MI ML4UJVI 2 UR AD ANCE�CITICE REQUIRED F INSPE TION -PLEASE CALL(209)9 3-7 97% _ SIGNED TITLE DATE � . .. '^ .12F- VVIPI"W111111"11IFT V"MIA". S'r - WIN q��'• '' "IllWNx ,ne f tA •` Y,ryry]yy�I>C ll.-.RY'. ��I�� C R 1 '-Mt 1r��110.'7C7��v .1_ ,. a" 1)17, i Y 'LpI � Y 1��y. Wt' ••.1.•�6. n Ni.�• 1 "�Y.' N I• �tt�. �j� :lV.wt It f �F �.r`, _ _ _ � -• S I DEPARTMENT USE ONLY A Application Accepted ByC Date 17 Area Employee ID# =5 L Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS m►Js T PE SC Received eck Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Re uest# �6(0 �� / `ir WELL/PUMP PERMIT EHD 43-06 4/30/12