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,/-� WELL/PUMP PERMIT IU !;/,N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT -L CALL 2099 953-7697 FOR INSPECTIONS EXPIRES/1 YEAR FROM DATE ISSUED JOB ADDRESS 2(. IN. QGF-�� ' �i /` CITY/ZIP Mt�l1�J Chi 1 mo m �'^ 'w D CROSS STREET w� 't' AP O 2 i{7O-y2 PARCEL SIZE/09 7VAND USE APPLIICCATION# OWNER NAME (��1✓�H- �Q� � � PHONE q() 2-' 23S-< w OWNER ADDRESS r.G . 32S CITY/STATE/ZIP C1,r ,^k+S CSI %2-Z77 CONTRACTOR 1"\AS C�I�) vl+�of tb., ( W%f• PHONE CONTRACTOR ADDRESS I1 01 A'10-e CITY/STATE/ZIP ModFS& C5, I, q535-7 SUBCONTRACTOR PHONE SUBCONTRACTO ADDRESS CITY/STATE/ZIP LICENSE ]757 El C-61 F-1 D-09 ❑Other NUMBER O Ls EXPIRATION DATE 2z DOMESTIC WELL SAMPLING:❑General 'neral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4 393) INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If ifferent from Owner: Water System N5me Contact Name or Phone Number TYPE OF WORK New Well [I Replacement Well F-1 Well Alteration/Modification El Other [:]Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings F-1 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 Mud' � ir Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other Proposed Well Depth ft Excavation '14 // in diameter ❑Open Bottom (Gravel Pack/Gravel Size in diameter ❑Concldctor Caslillhg m in diameter / Conductor Casing Depth ft Well Casing Diamefert in Thickness/Gauge/ASTM Sched LSWG Steel ❑Plastic E]Stainless Steel [-]Other Grout Seal Depth 5 O/ ft ❑Neat Cement(94 Ib bag/5-10 gal water) ,Sand Cement /6—3 sack mix17 gal water )On❑Bentonite(20%solids) ❑Other Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑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. MINUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697Q SIGNED �C TITLE ^T t'I�r DATE ^� DEPARTMENT USE ONLY Application Accepted By Date 1 Area 0y � Employee ID# '. Grout Inspection By r Date ❑ SPECIAL Well Permit Pump Inspection By Data ❑ WAIVER Received Soil Boring(Inspection By Date Constructed Well Depth ft COMMENTS 0I �( ��c �2s_.{�� -4r kill (i 7.t v✓� J" M PESC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 6el t 0 7 3 5 EHD 43-06 8/01/16 WELL/PUMP PERMIT