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�( ' WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE PERM((IT�� p c. GALL ZU9 953-7697 FOR INSPECTIONS EXPIKES 1 YEAR FROM LATE ISSUED JOB ADDRESS � C70 !� . 1 f C� AM CITY/ZIP CL,M Rc I 1 CROSS STREET TO � A Y) AAPN VV 0S PARCEL SIZE ^(_LAND USE APPLICATION # OWNER NAME -erCN (-A PHONE ' 61 'o o OWNERADDRESS o4-3(0 N. ?,,z CITY/STATE/ZIPpcamPnI CA qS a DO CONTRACTOR V CA1ve CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE ;.0-57 tt,C-61 ❑ D-09 ❑ Other, PHONE SC Received c Info ash Amount Remitted Date Permit/ Invoice # Well ID# Service Request # L436 CITY/STATE/ZIP C A G S 3 7? , % PHONE CITY/STATE/ZIP NUMBER 1 EXPIRATION DATE DOMESTIC WELL SAMPLING: &1eneral 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: Water System Name Contact Name or Phone Number TYPE OF WORK New Well ❑ Replacement Well ❑ Monitoring Well(s) # of wells ❑Out -Of -Service Well ❑Well Alteration/Modification El Other ❑ Soil Boring(s) # of borings ❑Geotechnical ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair # of borings New Pump ❑ Pump Replacement ❑ Pum Re air ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method 'Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth 07 ft Excavation i _� in diameter El Open Bottom XGravel Pack/Gravel Size 1/4 — in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _& in Thickness/Gauge/ASTM Sched C I ac C ❑Steel Plastic El Stainless Steel El Other Grout Seal Depth I OG ft ❑ Neat Cement (94 Ib bag/5-10 gal water) JA Sand Cement I U —� sack mix/7 gal water ❑ Bentonite (20% solids) ❑Other Grout Placement Method Wumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By kq Driller ❑ Pump Contractor ❑ Other JK Concrete Pedestal EDimensions: Width 4 ft Lengthft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible❑Turbine ❑Other HP Pump Set JC5 ft Standing Water Level 1 C 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 ANU AC i iVP WITH I hE �:ALiFORNiA CONTRACTORS STATE ATE LICENSE BOARD AND THAT 1 "ri IN CO."..'LIANCE :".11TH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FO\RI INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED �Ct �{fyuar TITLE 1 C C 2,(,e den A- DATE `03/ 17 T 1 m 0 m m or ur D PARTMENT USE ONLY Application Accepted By2ZZ4 ate / t, 7 Area 1� `I Employee ID# Grout Inspection By Date I t) I' / l� } ❑ SPECIAL Well Permit Pump Inspection By Date ID 11 --16 ❑ WAIVER Received Soil Boring Inspection By _ COMMENTS "�' 7( ; s ) Date 0;r S Constructed Well Depth ft PE Codes SC Received c Info ash Amount Remitted Date Permit/ Invoice # Well ID# Service Request # L436 f' 3 iVq 1 1, F IG31�(eG' 43� CSS C) 7? , % LIS _1 U U3_7 3 . EHD 43-06 8/01/16 WELL /PUMP PERMIT