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r WELL/PUMP PERMIT P� , SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-RhFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED !n JOB JUB ADDRESS L� CITY/ZIP m • D :ROSS STREET A I U7 -� PARCEL SIZE�_LA(\�_17USE APPLICATION## A OWNER NAME A O L PHO`N`E'IL�/ OWNER ADDRESS CITY/STATE/ZIP V�Az CONTRACTOR PHONE ✓e2) CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 I I C-61 U D-09 I-I Other NUMBER 4mu- EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Irrigation/Agricultural U Industrial I.1 Water Quality Monitoring u Soil Sampling/Characterization I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK a New Well 7 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings U Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair n New Pump _116purnp Replacement I I Pump Repair LI Raise Well Casing WELL CONSTRUCTION Drilling Method CI Mud Rotary ❑ Air Rotary LI Auger ❑ Cable Tool n Push Point ❑ Other Proposed Well Depth ft Excavation in diameter Fi Open Bottom n Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft Fi Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water D Bentonite(20%solids) LJ Other Grout Placement Method ❑ Pumped 11 Free Fall I I Other I1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller n Pump Contractor U Other ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in I I Christy Box U Stove Pipe PUMP Submersible❑ Turbine CI 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI ANCE NOTICE REQUIRED FO SP CTI NS - PLEASE CALL (209) 953697 SIGNED TITLE DATE '20 /10 fl IVA '1 11 M VA 1P'0 T 1-T DEPARTMENT USE ONLY Application Accepted Byi,4 Date 31 I Area v Employee IDJ& Grout Inspection By Date_ [.i SPECIAL Well Permit Pump Inspection By Date Q P WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# 3 z3l54 oj fW EHD 43-06 8/01/16 WELL/PUMP PERMIT