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, • WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT i^ I CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS/01 �/ v)Vti�� r d CITY/ZIP C�-(/�•' �.% SL� CROSS STREETS,_<'. l) ��/��j�AP/N� �/��!� 0 PARCEL SIZE J� LAND USE APPJLIICCATIONj#(/� OWNER NAME ✓ 7/✓�i / f s `l r / ►" r1" 1 , I - a'�/ J I� '� PHONE �Q ( OWNER ADDRESS C/(J V�'nJ.'�—O I//f ILIR// I � n J CITY/STATE/ZIP C L CONTRACTOR /`/"(�/aL�g�O ` I, V� `�� JWL'�I G�!�L Pomp PHJ'ONI (/ 1 ai'f ew CONTRACTOR ADDRESS %5(' y7 ClkCC -C. CITY/STATE/ZIP SUBCONTRACTOR AJ14 PHONE / . / H SUBCONTRACTOR ADDRESS � LICENSE '] C-57 ❑ C-61 ❑ D-09 ❑ Other CITY/STATE/ZIP / I ��7• NUMBER / J �7C EXPIRATION 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: Water bystem Name Contact Name or Phone Number TYPE OF WORK JaVew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other []Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method]MLid Rotar� El Air Rotary ❑Auger E] Cable Tool E] Push Point El Other Proposed Well Depth i/[� ft Excavation in diameter E] Open Bottom ravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diamet —2;K—in Thickness/Gauge/ASTM Sched_47 ❑Steel _,*lastic El Stainless Steel ❑Other Grout Seal Dep ft ❑ Neat Cement (94 /b bag/5-10 gal water)Sand Cement ey 4 sack mix/7 gal water Eltoni % solids) ❑ Other ' Grout Placement MethodJ�Pumpgd ❑ Free Fall El Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By O&Driller ump Contractor ❑ Other El Concrete Pdfdestal imehsions: Width ft Length ft Thick in [:]ChristyBox [:]StovePipe PUMP Submersible❑Turbine ❑Other HP Pump Set --a-10 � 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 HOUR ADVANCE NONCE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED, TITLE L��✓%�J '� DATE F !� T m 0 v m m rn N DEP RTMENT USE ONLY \ l��1 Appi, �i �•r , , c�N; : Sr Da,c ^ r E pl c In# !b _avLO) Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS lj/rat✓7 -5e-.fZ EHD 43-06 8/01/16 WELL /PUMP PERMIT Tri TRIMMED EHD 43-06 8/01/16 WELL /PUMP PERMIT