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LICENSE )R ADDRESS C-57 ❑ C-61 ❑ D-09 [:)Other T Y/STATE/ZIP EXPIRATION DATE )OMESTIC'WELL S MPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) NTENDED 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 ❑ New Well ❑ Replacement Well [-]Well Alteration/Modification F] Other ❑ Monitoring Well(s) # of wells El Soil Boring(s) # of borings ❑Geotechnical F1 Out -Of -Service Well I—]Out-Of-Service Well Renewal F]Cross-Connection Repair # of borings ❑ New Pum um Re lacement ❑ Pum Re air ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth 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 ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Benton ite (20% solids) ❑Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL In tailed 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 1 HEREBY CER FY 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. SIGNED Application Accepted 451 Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS ARTMENT U �L Date Date Date ..1. 11 Date T 1 m D v 0 m m ur cn Area Employee ID#�1rZ ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Sc Received Check#/ Amount Date Codes Info By Cash Remitted Permit/ Invoice # Well ID# Service Request # �Y WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT, CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS�• v CITY/ZIP I f , CROSS STREET li � APN PARCEL SIZE LAND USE APPLICATION # OWNER NAME PHONE ` L I W OWNER ADDRESS CONTRACTOR l 9 PHONE :� CONTRACTOR ADDRESS, CITY/STATE/ZIP SUBCONTRACTOR / PHONE LICENSE )R ADDRESS C-57 ❑ C-61 ❑ D-09 [:)Other T Y/STATE/ZIP EXPIRATION DATE )OMESTIC'WELL S MPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) NTENDED 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 ❑ New Well ❑ Replacement Well [-]Well Alteration/Modification F] Other ❑ Monitoring Well(s) # of wells El Soil Boring(s) # of borings ❑Geotechnical F1 Out -Of -Service Well I—]Out-Of-Service Well Renewal F]Cross-Connection Repair # of borings ❑ New Pum um Re lacement ❑ Pum Re air ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth 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 ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Benton ite (20% solids) ❑Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL In tailed 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 1 HEREBY CER FY 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. SIGNED Application Accepted 451 Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS ARTMENT U �L Date Date Date ..1. 11 Date T 1 m D v 0 m m ur cn Area Employee ID#�1rZ ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Sc Received Check#/ Amount Date Codes Info By Cash Remitted Permit/ Invoice # Well ID# Service Request # EHD 43-06 8/01/16 WELL /PUMP PERMIT