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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 '4 23 CALL 20 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �—I ' • CITY/ZIPi Cl'Y�r.-I m C 11 �� APN20 -(_61 - 1 j�ID o CROSS STREET 'w�yA1 / `a��f' -- f }�' 7"» PARCEL SIZE LAND USE/APPLICATION# A co OWNER NAME ! V e,,V1 1/ Y 1 4 �L U.,1 d A r < PHONE CJ 6-'- ril 3q3 �? OWNER ADDRESS 2�I2� ) ([ CITY/STATE/ZIP&CC'� � �1-" l" .3� J CONTRACTOR 4�Y �CjyS V- t i l 'r IA C l I I U INT PHONE f�L " / f L CONTRACTOR ADDRESS b in A e rCITY/STATE/ZIP I" I JQf 6s, , �1 J✓✓ SUBCONTRACTOR PHONE j SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / �a LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER A EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)i-I Dibromochloropropane(4392) L Arsenic(4393) INTENDED USE ❑ Domestic/Private >(Irrigation/Agricultural ❑ Industrial U Water Quality Monitoring U Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK )eNew 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 Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing ' WELL CONSTRUCTION Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation 1 _ in diameter U Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter bL in Thickness/Gauge/ASTM Sched �> 1>kSteel ❑ Plastic ❑ Stayless Ste I [],Other Grout Seal Depth �C> ft Ll Neat Cement(94 Ib bag/5-10 gal water) �f'Sand Cement -� ?C sack mix/7 gal water ❑ Bentonite(20%solids) Li Other Grout Placement Method 7tnmped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Xrp 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 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 ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENS N LAWS. MINI M OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95y3-76`97 SIGNED �� .�� TITLE r DATE f '/FS Z a I s r` a t / PBE 6 DE ? i; RTMEivT USE NL rr,'r �irJ Application Accepted By Date V Area Employee ID# Grout Inspection By VM Fa2L44YIkk_Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date PermiU Invoice# Well ID# Codes Info B as Remitted Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT