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SAN JOAQUIN COUNTY ENVIRONMENT <br />NON-REFUNDABLE PERMIT f <br />JOB ADDRESS l (oAI ,go <br />CROSS STREET/46 - `6 r ii / <br />OWNER NAME 5 %,4 I <br />OWNER ADDRESS II q <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />WELL/PUMP PERMIT e ✓ <br />HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />o /�% CrrYlZn, S TN "a cls0 4-1 <br />I <br />r2^- rrAPN (jp -O / O _`� 10 PARCEL SIZE �?2*6 LAND USE APPLICATION # <br />N�Fi�p 5c L C PHONE A/ �n <br />�i- ? NAL rE CITY/STATE/ZIP ✓�"1 CA q�✓'� <br />PHONE -20q _ q4, —7 / 7O✓n <br />CITY/STATE/ZIP <br />_6i4L7 —C A qSO 3Z <br />PHONE <br />CITY/STATEIZIP <br />LICENSE X C-57 ! C-61 Ll D-09 Other NUMBER.2O 10 EXPIRATION DATE Y �O —� <br />DOMESTIC /WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private 7 Irrigation/Agricultural Industrial IWater Quality Monitoring Soil Sampling/Characterization <br />7 Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well IReplacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bonng(s) a of borings X -Geotechnical (:P- a of bodrgs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pum2 Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary 7 Air Rotary X Auger Cable Tool Push Point Other <br />57 // <br />Rf� <br />Depth �_k Excavation 6 in diameter 5 Open Bottom Gravel Pack/Gravel Size in diameter <br />f� Conductor Casing n diameter / Conductor Casing Depth ft <br />Well Cas g Diameter _ in Thickness/Gauge/ASTM Schad 17 Steel Plastic Stainless Steel '._ Other <br />Grout Seal Depth �_ft Neat Cement (94 /b bagi5-10 gal water) 5 Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped :. Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller - Pump Contractor Other <br />Concrete Pedestal CDimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP Submersibles.: Turbine I:! Other HP Pump Set k Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA I ,LAWS. <br />MINI�MQ/U I VANCE NOTICE REQUIRED FOR <br />jINSPECTIONS <br />.- PLEASE CALL (209) 95377697 <br />SIGNED �'�"" TITLE �/' ' • • 64� 'Ajr_r— - DATE 5- '?-10P <br />A <br />N <br />EP TMENT USjtO LY <br />Application Accepted By Date Ch V v Area Employee ID# <br />Grout Inspection By Date PECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />lo",FROWM MOM "'T <br />Sa Permit/ <br />EHD 4306 8/01/16 <br />WELL /PUMP PERMIT <br />N <br />