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Tv,'4"1 11-a- 16 0�*-t WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT�/ AI, CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / /��'`t��, ��p CITY/ZIP /ry \ OR�J 4 CROSS STREET w�L Y \,t. �APPN(�_5Q t/�J�O PARCEL SIZE� LAND USE A,PPPLLIICATION#�/ `� O OWNER NAME Ry t�)t�/'�t� Jd PHONE(/ ( —73t6 ( —/"� N OWNER ADDRESS l� v� �N V V J� CITYISTATE/ZIP CONTRACTOR PHONE /r/o --7/V CONTRACTOR ADDRESS V w CITY/STATE/ZIP 1A3IL,Q4 cA r ct�SUBCONTRACTOR PHONE PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP ''��L '7 �'I` LICENSE C-57 EIC-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE4--66 t, DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (439 1)❑Dibromochloropropane (4392)[]Arsenic(4393) INTENDED USE -gDomestic/Pdvate`Kirrigation/Agricultural [-]Industrial ❑Water Quality Monitoring [I Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or one um er TYPEOFWORK -ANeWWell ❑Replacement Well ❑Well Alteration/Modification El Other ❑Monitoring Well(s) #ofwells ❑Soil Bodng(s) #of borings ❑Geotechnical #of borings El Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pum [I Pump Replacement Ej Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method El Mud Rotary []Air Rotary ❑Auger Cable Tool F1 Push Point ❑ Other Proposed Well Depth*7ZM ft Excavation in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter [jConductor Casing in diameter / Conductor Caging Depth ft Well Casing Diameter6— in Thickness/Gauge/ASTM Schad 1 1 0% �teel ❑Plastic E]Stainless Steel ❑Other Grout Seal Depth 0 it ❑Neat Cement(94 Ib bagl5-10 gal water) Sand Cement 10,,3 sack mix/7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By filler E]Pump Contractor Other ❑Concrete Ped stat IPimensions:Width ft Length ft Thick in [-]ChristyBox ❑Stove Pipe PUMP Submersible❑Turbine ❑Other HP Fy 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. MINIM 2y4 H_ OUR 9 V E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED / \/ TITLE O "ON EZ— DATE ' ` ok ,DEFIARTMENT USE ONLY Application Accepted Date 6 Area Employee ID#�-rJ Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Codes Well Codes Info B Cash Remitted Service Request# 307 ✓' Z 0 n7 ° 1 12 I&ILWOOD 0 1 6 EHD 43-06 8/01/16 WELL/PUMP PERMIT