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• WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NONREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS A by ZZ il/(r L' r n�u !�v� CITY/ZIP S {u�IG {�,, /-7 k G CROSS STREET o r APN (11 40 ZY — Z 3 PARCEL SIZE 30 - LAND USE APPLICATION # 1- �J1 o x-!56 c� C,( cjrc �-_.� C. _'� 3 7.4 OWNER NAME PHONE fi / N, - T��SM - /2 OWNER ADDRESS - { v Y v I r�LtiC_ s CITY/STATE/ZIP_©`rc/J G� vTT ' '1'2-916 CONTRACTOR PHONE `%116 ?il CONTRACTOR ADDRESS 31 �{ , c ., ��v eI CITY/STATE/ZIP We I* Siti .rte +�- I., . G4 SUBCONTRACTORtrop.. d 1ya�n ,. �� PHONE fj7-i - 3i Z- r D SUBCONTRACTOR ADDRESS 7" A.: � (V / `2-'i -7 CITY/STATE/ZIP t\4t,4t— ,(.1 y—�T i � All � (J( jr--i LICENSE X -C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 4'2 )'%,63 EXPIRATION DATE DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0( 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 ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 5 Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump E. Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth -10 ' �y ft Excavation _� 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 ❑ Stainless Steel ❑ Other Grout Seal Depth Q - b ft ya..Neat Cement (941b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite (20% solids) at t)tnuT Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other Tre/Yru�. ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft 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 HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED / «...� _ TITLE S 10' IAFf 46/w1 "jL DATE 2-hW l i C EPARTMENT USE ONLY Application Accepted By _02::SDate,2, h 2=112. Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By i Date COMMENTS Z.�Zv�2 v/ ri,' �, s {l ..rt4— A,, T m D 0 0 m m Ch Area / FkN Employee ID#""J, ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE SC Received iheck ' Codes Info ash Amount Date Permit/ Invoice # Well ID# Remitted Se ice Re ues # % i S 0 y EHD 43-06 8/01/16 WELL /PUMP PERMIT