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WELL/PUMP SPAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PERMIT �� (01 -3 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVVIV-KFFUNDABLE PERMIT L;ALL (ZUy) U53 -/b9/ FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 16 E L h rrvK;e r 4 A -d' CITY/ZIP _ ,5/y ex fil'i IS, 2=Z ✓� CROSSSTREET ,%11.5 h /e V Lanz APN CA 7 PARCEL SIZE 3(',3Y' LAND USE APPLICATION # OWNER NAME 1 QCT l k -c o 11 PHONE .��! y - Z��3 - . 3L S. OWNER ADDRESS "?j4 -,V E7 G� F C J /_4�ZI CITY/STATE/ZIP / c �C lu!hf cf/; CONTRACTOR ✓Vt; 11 ©. 1$jdeg-un 4:gie;' CONTRACTOR ADDRESS I, uC �/ IL%%/sr%'l C G4/4u IPH�IO,NE CITY/STATE/ZIP -Ce 1 /A , C (-)5J9eC' SUBCONTRACTOR 1 '- PHONE SUBCONTRACTOR ADDRESS LICENSE [PC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER CITY/STATE/ZIP EXPIRATION DATE DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring [Soil Sampling/Characterization ❑ Public Water System If different from Owner: a er ys em Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑Monitoring Wells) # of wells El Soil Boring # of borings s) [,Geotechnical # of borings ❑Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair ^/� ❑ New Pum El Pump Replacement El Pump Repair ❑ Raise Well CasingPA WELL CONSTRUCTION ZCE71/ Drilling Method E] Mud Rotary ❑Air Rotary Auger E] Cable Tool E] Push Point El Other C Proposed Well Depth -;I C_ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravellameter F] Conductor Casing in diameter / Conductor Casing Depth ft SAN �� Well Casing Diameter in Thickness/Gauge/ASTMSched ❑Steel ❑Plastic E] Stainless Steel EF40"Cp61T�� Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) E]nos Sand Cement ZALTH �ie�Cl gal water ❑ Bentonite (20% solids) ®,Other �(" I C c / U1 �"'�tNT Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other El Retardant /Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other E] Concrete Pedestal EDimensions: 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. MINIMUM 24 HO`]URA (/DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED J '74 . V�" TITLEL �'ult ��llyll kl�/G'DATE z S D PARTMENT USE ONLY Application Accepted By Date Grout Inspection By Date Pump Inspection By Date Soil Boring InJpectionBy. Date COMMENTS /I//7 Imo/) S" ' Area q ! 1 6- Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft T PE Codes SC ReceivedChe Info ash Amount Date Permit] Invoice # Well ID# Remitted S rvice Request # 4372 IS, 2=Z 3,- 6 EHD 43-06 8/01/16 WELL /PUMP PERMIT