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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 C LL 209 953-7697 FOR INSPECTIONS E IKtS 1 YEAR FROM UATE ISSUED JOB ADDRESS y CITY/ZIP CROSS STREET APN ©bl-61f] 4 PARCEL SIZE LAND USE APPLICATION #� OWNER NAME PHONE + 4Q42 S ✓✓-L OWNER ADDRESS CITYISTATE/zip—LLL' I IcA635?:Y0 CONTRACTOR PHONE�� CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTO ADDRESS CI STATE/ZIP LICENSE -57 ❑ C-61 1 1 D-09 ❑ Other NUMBERWffd—& EXPIRATION DATE j )OMESTIC WELL SAMPLING: ' General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 ❑ Geotechnical # of borings ❑ Out -Of -Service /Well [I Out -Of -Service Well Renewal LI Cross -Connection Repair 11 New Pump �Y7 PumD ReDlacement Ll Pump Repair ❑ Raise Well Casing Drilling Method ❑ Mud Rotary ❑ Air Rotary LI Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter I 1 Open Bottom CI 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 ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) U Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP q Submersible❑ Turbine CI Other HP Pump Set ft Standing Water Level ft 1 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. E DE ARTMENT U E N Y Application Accepted By�VA Date Area Employee ID# Grout Inspection By Date ❑ PECIAL Well Permit Pump Inspection By Date O 41I ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS J�) cte4, �� Lk� o l �I P T M D 0 0 rn m U) N PE SC Received Check#/ Amount Permit/ Date Invoice # Well ID# Code Info B Cash mifted Service Re uest # S S 1 7 EHD 43-06 8/01/16 WELL /PUMP PERMIT