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A) WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS (� `l CITY/ZIP CROSS STREETS ✓ (��( I APN YO �'/ I ©V �� PARCEL SIZE LAND USE APPLICATION # OWNER NAME C ` C �1 ('` 1`l �,1 { rC�� _ PHONE 1 I lY t..Y 2T4 1 OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR V V (� CITY/STATE/ZIP. PHONE CITY/STATE/ZIP PHONE IV SUBCONTRACT R ADDRESS I // t CITY/STATE/ZI IP (� LICENSE C-57 ElC-61 ElD-09 E]Other NUMBERAI LX EXPIRATION DATE DOMESTIC VLLL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) NTENDED USE ❑ Domestic/Private 91rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name uontact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other El Monitoring Well(s) #of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings F] Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair ❑ New Pump Wump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter F-1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic El Stainless Steel E] Other Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water E] Bentonite (20% solids) F-1 Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other [�Sqmwete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible Turbine ❑Other HP 2-6- 30 Pump Set ft Standing Water Level ft I HEREBY CERT AVE 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 E UtF'AK I NItN I U 0 r UUNL T ) Application Accepted By Date ` 0 1f Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS T m D 0 v m m rn in Area �iqq Employee lD# A-hrAo (• ❑ S ECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Sc Received Check#I Amount Date Permit/ Invoice # Well ID# Codes Info B Remitted ervice Request # 4 cj EHD 43-06 8/01/16 WELL /PUMP PERMIT