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CU7 = L .off WELL/PUMP PERMIT SAN JOAQJN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 v NON-REFUNDABLE PERMIT PALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rr J j� � JOB ADDRESS �J C' GL/�I� �/!'/f/Jf,�\ /Le J CITY/ZIPm CROSS STREET / Gy\']a�. 'L— APN (il�}�l )/ PARCEL SIZELAND USE APPLICATION# v `�,. A 'SD NAME �e�®� /t/ L(L�P \ Cn PHONE � ((�J y�� v� OWNER ADDRESS �(/� l CITY/STATE/ZIP f�z a(,i' {^� �y-( JLi►r[ CONTRACTOR LJrc Z�I 1 �`P�HONE ZL� L el / CONTRACTOR ADDRESS (/ Q/� 1�3 CITY/STATE/ZIP [�".\ re SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STAT-E//ZIP LICENSE ? ElC 61 E]D-09 ❑Other NUMBER / EXPIRATION DATEJ) D DOMESTIC WELL SAMP G:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Gontact Name or Phone Number TYPE OF WORK ❑New Well N<eplacement Well ❑Well Alteration/Modification El Other ❑Monitoring Well(s) #of wells ❑ #of borings SoilBoring(s) ❑Geotechnical #of borings F1 Out-Of-Service Well E)Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method ON ud Rotary El Air Rotary El Auger ❑ able Tool E]Push Point ❑ Other Proposed Well Depth ft Excavation in diameter El Open Bottom el1ravel Pack/Gravel Size S in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched Zoo_ ❑Steel stic ❑Stainless S eel []Other Grout Seal DepthMID_ft El Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water ❑Bentonite(200 olids) ❑Other Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ump 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 COMPENSATIO S. MINIM!!!4 HO ADV CE OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7097 SIGNED TITLE �' �" DATE � � 1 e AlU L 11 c c EM I + C I mlpema 7 'PARTMENT USE ONLY C Application Accepted By _ Date Area Employee ID# Grout Inspection y Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENT ? P rfAfi 1 41J ' A PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# (9 C4 �: 3 0 o 0 POE I - 3 U 0-70 EHD 43-06 8/01/16 WELL/PUMP PERMIT