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WELL/PUMP PERMIT SAN JOAQUII!COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NQN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS (1 I CITY/ZIP t ' q5 m CROSS STREET APN 0 1 2 UO PARCEL SIZE rl S p LAND USE APPLICATION# ' A OWNER NAME villa-i^ art PHONE /�l�y ';/y t -L4/ / N OWNERADDRESS P1J �y�/� Clt C (� CrTY/STATE/ZIP (,r�kl{!_Sdn:G j CIE C1`�23LP CONTRACTOR � y�t � Y"�Il� PHONE /p f7, CITY/STATE/ZIP 6?5 e' CONTRACTOR ADDRE S Q �j I SUBCONTRACTOR - PHONE �-1 �/•2-1—- SUBCONTRACTOR ADDRESS CITY/STATE/ZIP r LICENSE C-57 rC-61 U D-09 [I Other NUMBER (V'IPEXPIRATION DATE 131 Lq DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private Irrigation/Agricultural 11 Industrial I1 Water Quality Monitoring ❑ Soil Sampling/Charas Ne—Nr ❑ Pu blic Water System �.If different from Owner: Water System Name Contact Name or Phone Numbe ' TYPE OF WORK -i New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other A on lJ Monitoring Well(s) #of wells ❑ Soil Boring #of borings -11 ofgs) ❑ Geotechnical 0'8 1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair — OAQUI New Pum [I Pump Replacement ❑ Pum Repair F] Raise Well CasingEIRON N COUNTY WELL CONSTRUCTION EPARTMENT Drilling Method )(Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation �— in diameter I I Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conducto Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in T kness/Gauge/ASTM Sched LI Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth Il Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) [I Other Grout Placement Method YPumped ❑ Free Fall CI Other I.1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Pump Contractor I I Other Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine i I 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. MINIMUM HOU NCE NOTICE REQUIRED FO I SPECTI NS - PLEA SE CALL (209) 7607 SIGNED TITLE DATE 1 ti 1 DEP TMENT U E N L Y r- Application Accepted By Date Area Employee ID# Grout Inspection By Date [1 PE AL Well Permit Pump Inspection By Date ❑ WAIVER Received pt� vu Soil Boring In ection By Date Conn trusted Well Depth ft COMMEN ,SSV✓/GL owl, SCP ALf&W PE SC Received � Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# IiAll 3q �v v S u 7 y I 20 I 0 2 EHD 43-06 8101/16 WELL/PUMP PERMIT