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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 9$205 - (209)468-3420 NON-REFUNDABLE PERMIT 4� CALL 209 953-7697 FOR INSPECTIONS EXcPPIR�EES11 YEAR ROM DATE ISSUED u+ CITYIZIP \ /V�-/� �� `�ZI7, m JOB ADDRESS PARCEL SIZE LAND USE APPLICATION# z GROSS STREET APN /� U��nr m r / [•� �tI ,.�W PHONE��V C�/7�•-(J 0 y OWNERNAME �f,�/�b�>.s �5 • I4�� (,{�q Z{ G� CA OWNER ADDRESS CITYISTATEIZIPS-IV"' -2 '7IZL� L �I��1 ., Z'� J)_ CONTRACTOR S PHONE / ''''tom CITYISTATEIZIP Z�f/Ores CONTRACTOR ADDRESS 2t? PHONE SUBCONTRACTOR CITY/STATE/ZIP SUBCONTRACTOR ADDRESS �� - 6-/7 LICENSE C-57 FIC-61 [ID-09 ❑Other NUMBER EXPIRATION DATE DOMESTIC WELL-SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)[]Arsenic(4393) INTENDED USE *aomestia'Private ❑Irrigation/Agdculluial ❑Industrial ❑Water Quality Monitoring E]Soil Sampling/Characterization El Public Water System a er ys em ame on a ame or one um er If different from Owner: TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other #of borings Li monitoring Well(s) #of wells [:]Soil Boring(s) #of borings ❑Geotechnical ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair IgNew Pump E]Pump Replacement E]Pump Repair ❑Raise Well Casin WELL CONSTRUCTION Drilling Method E]Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth' ft Excavation I L in diameter ❑Open Bottom 1,P&ravel Pack/Gravel Size in diameter ❑Conductor asmg in diameter / Conductor Casing Depth ft Well Casing Diameterin Thickness/Gauge/ASTM Sched7'IV _ []Steel �lastic ❑Stainless�Steel, ❑Other Grout Seal Depth M ft ❑Neat Cement(94 Ib bagi5-10 gal water) >asand Cement /(JAL—sack mix17 gal water ❑Bentonite(20%solids) ❑Other C Grout Placement 111l Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Wriller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Epimensions: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 COMPENSATION LAWS. MINI M 4 H R ADVANCE NOTICE REQUIRED FOR'INSPECTIONS -PLEASE CALL 953-7`69/7 SIGNED - TITLE VW/ � DATE/�i �� ` UN O DEPARTMENT USE ONLY HEALTH DEPARTMENT � � Application Accepted B1- Date p �7,0l Area "L�! Employee ID# o Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth it r COMMENTS E ece ved Check#1 Amount Date Permit/ Invoice# Well ID# Codes fo B Cash Remitted Service Re uest# b R 7 0�0 1 3 314 0-`' (SER t3 �8 -°' 6 I Roo Z'1 WELL[PUMP PERMIT EHD43-06 8/01/16