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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 r,',JN-KEFUNDABLE PERMIT CALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS ( 1-, T CITY/ZIP r1Z CROSS STREET ��/ ,� APN � � '� a�,�' �lp PARCELSIZE BLAND USE APPLIICCAA�T'ION # OWNER NAME D/% fJ. T j��/�t](�i,�1J��;�/.` !y%/mac �-Y PHONE y/ �7ilGy�r OWNER ADDRESS / J 1 _ ��^ © Nr� 44eW�1�E/ZIP / J Z� CONTRACTOR PHONE c e";495Z—f� CONTRACTOR ADDRESS �L.( �, � /U// feJ �� CITY/STATE/ZIP -S- SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS LICENSE V-57 ,Z-61 ❑ D-09 ❑ Other CITY/STATE/ZIP NUMBER [!/�004"/-7Z EXPIRATION DA DOMESTIC WELL SAMPLING: ❑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 ------- C-o-niact Name or Phone Number TYPE OF WORK ❑ New Well Oeplacement Well ❑ Well Alteration/Modification ❑ Other vV/ # of borings P rings []Monitoring ells) # of wells ❑Soil Boring(s) ❑Geotechnical A ANT F] Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair RECEIVED Wlew Pump 171PumpReplacement F-1PumpRepair —(Raise Well Casina .... WELL CONSTRUCTION "V` U 2017 Drilling Method &/lud Rotary ❑Air Rotary ❑Auger []CableTool E] Push Point ❑ Other SAN JOA Proposed Well /Depth 180 ft Excavation in diameter E] Open Bottom []Gravel Pack/Gravel Sf2erHo�ALin diameter F1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched GL -Z E] Steel Mastic []Stainless Steel ❑Other Grout Seal Depth ft El Neat Cement (94 Ib bag/5-10 gal water) /❑ Sand Cement sack mix17 gal water 1-9dBentonite (20% solids) ❑Other Grout Placement Method ❑ Pumped [:]Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other ❑ Concrete Pedestal Imensions: Width __q ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP &Submersible❑Turbine ❑Other HPI Z-;?- Pump Set fM ft Standing Water Level 7§ _ 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. AA4 VANCEiNOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76 7 SIGNED 1J L� l�rl�L TITLE 1W DATE 7 =%2--7 �ocu �tst2 j IZD r J" � I z , 1/si 21 ��j� h g2�j rrc7 DEPARTMENT U E LY T Application Accepted By Date Area Employee ID# Fv Grout Inspection Byis Date ElPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Ins ection By COMMENTS I MIn I Date Well ft T PE Sc Received Q.2he Anfirunt Date Codes Info By,, Cash Remitted I I Permit/ Invoice # ell ID# Service Request # 1 " -7/ . J !/ 4,1 e co — 9 -V77—C6� EHD 43-06 8/01/16 WELL /PUMP PERMIT