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WELL/PUMP PERMIT UNTY E�{VIRONME�NTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 INC -REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS 1 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS .�S600 NTaC+hacA Ay CITY/zIP 4�C� / (2A ��`JZy� m �Z APN ©S t C� I�J D nn PARCEL SIZE LAND USE APPLICATION# a �J CROSS STREET i � q OWNER NAME (f-7 `��L� 7 rll &K-0 n•' L `�'� I PHONE Zrcl 5Z 7 -3 33�12 �? OWNER ADDRESS �` CA C. l` CITY/STATE/ZIP Lu J` (' A °)5 a Z CONTRACTOR l_ 3M*), ( PHONES% low CONTRACTOR ADDRESS �c�-G1 "-qcn-� ad CITY/STATE/ZIP VA—heq-J_P1W'7e7- 5-Z-5-'-1'3 &A SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER IjQlExPIRATION DATE 3 / DOMESTIC WELL SAMPLING:IgGeneral Mineral/Coliform Bacteria (4391)toDibromochloropropane (4392)❑Arsenic(4393) INTENDED USE Domestic/Private ❑Irrigation/Agricultural []Industrial ❑Water Quality Monitoring []Soil Sampling/Characterization ❑Public Water System If different from Owner: Water bystem Name Contact Name or Phone Number TYPE OF WORK ,New Well [j Replacement Well ❑Well Alteration/Modification El Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings ❑Geotechnical 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 Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other Proposed Well Depth 3 /a ft Excavation &' �'L in diameter ❑Open Bottom „Gravel Pack/Gravel Size(,in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel Plastic El Stainless Steel ❑Other Grout Seal Depth ? ft ❑Neat Cement(94 lb bag/5-10 gal water) [Sand Cement sack mix17 gal water ❑Benton ite(20%solids) ❑Other Grout Placement Method 56Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contractor ❑ Other E]Concrete Pedestal O)imensions:Width ft Length ft Thick in [:]ChristyBox ❑Stove Pipe PUMP JQ Submersible❑Turbine ❑Other HP J() Pump Set j ft Standing Water Level 4C> 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. MINIM OUR ADVA E TICE REQUIRED FOR INSPECTIQ S - PLEASE CALL (209) 953-7697 SIGNED �' f� TITLE DATE S Z I I l � 'A vii Coup Fpt, DEPARTMENT USE ONLY J _ lam' ��- Area l ��GI Em to Application Accepted By � Date ee ID#p y Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By a Date ❑ WAIVER Received _ Soil Boring Inspection By Date Constructed Well Depth 3 � 0 ft COM NTS t\e( KP d W 4 n rtrt, ,io an (^ A!\d f r-s ir• � PE C Received heck Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Request# g3t;b ITU V21 a3e) 1 Iy5 41 g b S Cl •''' ( " EHD43-06 8/01/16 �jf� F'S-z 7 WELL/PUMP PERMIT