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WELL/PUMP PERMIT 1& /41 SAI'.'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 t,p 1C L1Z'1 CITY/ZIP Ara. pr. i r � m �J i D CROSS STREET f,(> ' 1 F APPNN wC9 11,�p 1 a 0 `� �rPARCEL SIZE 3-6,WLAND USE jA�PPLICATION# A OJ NER NAME 10 :^1� � 1 ere`.;1 � TI �1I�Iw5 �T �I PHONE 6L422 OWNER ADDRESS .�1 ��' F-t':'A y�l c CITY/STATE/ZIP A l C.,M P f,, c1, CONTRACTOR ��/ $S(y1't S �f� 11 1 N`�{\�• PHONE CONTRACTOR ADDRESS 119 A IV,u-> Ii`-A CITY/STATE/ZIPY SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ` I LICENSE ')<C-57 IL C-61 ❑ D-09 ❑ Other NUMBER �'�r)�f` / EXPIRATION DATE DOMESTIC WELL SAMPLING: XGeneral Mineral/Coliform Bacteria (4391) xDibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 11 Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WO19y .New Well Replacement Well ❑ Well Alteration/Modification Ll Other ❑ Monitoring Well(s) #of wells [I Soil Boring(s) #of borings I I Geotechnical #of borings ❑ Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement Ll Pump Repair CI Raise Well Casing WELL CONSTRUCTION Drilling MethodMud Rotary LlAir Rotary 11Auger a Cable Tool Ll Push Point 11 Other Proposed Well Depth �j ft Excavation � in diameter ❑ Open Bottom K.Gravel Pack/Gravel Size — in diameter Ll Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter L in Thickness/Gauge/ASTM Sched (% ❑ Steel 1.tplastic Ll Stainless Steel 11 Other Grout Seal �D,epth 'L,O.0 ft [I Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water k 5entonite(20%solids) ❑ Other Grout Placement Method XPumped F1 Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller J Pump Contractor l� Other 11 Concrete Pedestal ❑Dimensions:Width It Length ft Thick in ❑ Christy Box L1 Stove Pipe PUMP ❑ Submersible[] Turbine 1_1 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. IV fINWUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED �� — � L TITLE O f"t 1 f p P DATE L4' 11— AA 1— 1 � \ ti -1c fJ 5 E r v M DEPARTMENT USE ONLY ]� Application Accepted By Date-14-1 Area C C Employee ID# " On Grout Inspection By Date U SPECIAL Well Permit Pump Inspection By Date _I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Ch Amount Date Permit/ Invoice# Well ID# Codes Info By_ Cash Remitted Service Request# 37 y3�i I q5 Ll 3 70 7 EHD 43-06 8/01/16 WELL/PUMP PERMIT