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C WELL/PUMP PERMIT 15 " SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL209 953-7697 FOR INSPECTIONS EXPIRES �1 YEAR FROM DATE ISSUED JOB ADORE �/"'/�jS� / f Se A/ CITY/ZIP_,I/V �i'�✓ 4��Ni CROSS STREF,1.�!C 7� + t� dA,PN /PARCEL SIZE LAND USE A,PgPLICATION #('/ J OWNER NA fC �C�C�(:/!��/t CJD VrL L PHONE Z` �'y,Sid 'SR7 OWNER ADDRESS Ul/(� �1 ' �f CITY/STATE/ZIP y // is CONTRACTOR ,Q�Al2P 1/��LL/li ✓G' C —0-t A!,yY �J/PHONE 7 0 ~J` �7 7 �r 6! CONTRACTOR ADDRESS �% /��' CITY/$TATE/ZIP,N �/ 5��C• y47 SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE57 U C-61 ❑ D-09 ❑ Other NUMBER CITY/STATE/ZIP PHONE EXPIRATION DAT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) INTENDED USE 0 Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I Water Quality Monitoring jsail-Sampling/Characterization Cl 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 ElMonitoring Well(s) # of wells # of borings Geotechnical �# of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cl Cross -Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ud Rotary ❑ Air Rotary C14uger ❑ Cable Tool I I Push Point ❑ Other Proposed Well Depth L3 r ft Excavation _41 4 in diameter I 1 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 ❑ Plastic F1 Stainless Steel F1 Other Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 g / water) LI Sand Cement sack mix/7 gal water I I Bentonite (20% solids) ❑ Other 7— Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other W-- I 1 Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor CI Other Concrete Pedestal F1 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 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. INI'I)AU/M�48 HOUR DVANCE NOTI UIRED FOR INSPECTIONS - PLEASE CALL (209) 95/3-766/97/ SIGNED �/l�1.�� l TITLE �/C Al C 1X4 L DATE Ln m D v v M in Cn DEP RTME4T U E N LY 11 Application Accepted By Date L / Area Employee ID#A&fw Grout Inspection By Q �JGM�i>IL�Date [ t Cl SPECIAL Well Permit Pump Inspection By Date Ll WAIVER Received Soil Boring/I�spection By COMMENTS 9Dr&io Date Constructed Well Depth PE SC Received ec Amount Date Permit/ Invoice # Well ID# Codes Info B Remitted Service Re uest # 03 ft EHD 43-06 8/01/16 WELL /PUMP PERMIT