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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 [I Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well I_I Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump `(Pump Replacement ❑ Pump Repair ❑ Raise Well Uasing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool LI Push Point ❑ Other Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I_I Steel I I Plastic I1 Stainless Steel ❑ Other Grout Seal Depth ft I1 Neat Cement (94 Ib bag/5-10 gat water) [I Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑I Pump Contractor Ll Other ❑ Concrete Pedestal UDimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine I_i Other HPZ- 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. M _ 24 OUR ADVANCE NOTICE REQUIRED O�V�PMVLEASE CALL ((209) 9 3 7697//SIGNED 27 MIA USE O LY Application Accepted By Date Grout Inspection By Date Pump Inspection By l Date V Soil Boring Inspection By Date COMMENTS Area l ` Employee ID#� C] SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# Codes Info By Cash Remitted Service Request # d - EHD 43-06 8/01/16 WELL /PUMP PERMIT T m D 0 0 m m rn J WELL/PUMP PERMIT j 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 XPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS H CITY/ZIP CROSS STREET (, Q APN 6 R9 © � 1 PARCEL SIZE LAND USE APPLICATION # 0 '�1 C T4� �t i� PHONE I ✓ �' �J `� OWNER NAME OWNER ADDRESS O I CITY/STATE/ZIP—CA O SZQ-----T MODW 1 � /1 CONTRACTOR PHONE v `� CONTRACTOR ADDRESS L— CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �f Apt I LICENSE F1 C-57 ❑ C-61 F1 D-09 1 Other NUMBER O VQ EXPIRATION DATE DOMESTIC WELL SAMPLING: 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 System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells [I Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well I_I Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump `(Pump Replacement ❑ Pump Repair ❑ Raise Well Uasing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool LI Push Point ❑ Other Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I_I Steel I I Plastic I1 Stainless Steel ❑ Other Grout Seal Depth ft I1 Neat Cement (94 Ib bag/5-10 gat water) [I Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑I Pump Contractor Ll Other ❑ Concrete Pedestal UDimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine I_i Other HPZ- 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. M _ 24 OUR ADVANCE NOTICE REQUIRED O�V�PMVLEASE CALL ((209) 9 3 7697//SIGNED 27 MIA USE O LY Application Accepted By Date Grout Inspection By Date Pump Inspection By l Date V Soil Boring Inspection By Date COMMENTS Area l ` Employee ID#� C] SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# Codes Info By Cash Remitted Service Request # d - EHD 43-06 8/01/16 WELL /PUMP PERMIT T m D 0 0 m m rn