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_ 1 WELL/PUMP PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REAINDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS E PIRES 1 YEAR FROM DATE ISSUED to JOB ADDRESS CITY/ZIP m CROSS STREET AA V PARCEL SIZE� AND USE APPLICATION# S OWNER NAME V ' PHON tyx- 00-7 N D Q&99)a Mj -- ST ADDRESS CITY/ AT ` ,CONTRACTOR ` PHONE// �/ I ✓�—LFj CONTRACTOR ADDRESS /� CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS C Y/STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE ✓/� DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) ' Arsenic(4393) INTENDED USE ❑ Domestic/Private VIrrigation/Agricultural i I Industrial [l Water Quality Monitoring LI 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 kohn [1 Monitoring Well(s) #of wells 11 Soil Boring(s) #of borings F1Geotechnical #MAY`'g� Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair J 208 l❑ New Pum Pump Replacement 11 Pump Repair F1Raise Well Casing SAN JOq WELL CONSTRUCTION HTND N E , jEFNT,4L Drilling Method Mud Rotary 11ElAir Rotary ❑ Auger Cable Tool i 1 Push Point Li Proposed Well Depth Oma% ft Excavation in diameter I Open BottomGravel Pack/Gravel Size 6,144i4diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter fQ in Thickness/Gauge/ASTM Sched L] Steel F1Plastic ❑ Stainless Steel P Other Grout Seal Depth._. 5Z0 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water )B entonite(20%solids) fl Other Grout Placement Method 11 Pumped U Free Fall ❑ Other FI Retardant/Accelerator(name) PEDESTAL Installed By LI Driller R% Pump Contractor LI Other ❑ Concrete Pedestal F]Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP rt.Submersiblel] Turbine ❑ Other HPPump 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 ORD ANCES, 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 COMPENON LAWS. MINI DVANCE NOTICE REQUIRED FOR INSPECTI NS - PLEASE CALL (209) 953-76970 SIGNED ' "L T TLE DATE Q \b iIle jv D/E TMENT USE /ONLY Application Accepted By Date Area Employee ID# Grout Inspection By Date (f [IPECIAL Well Permit Pump Inspection By Date } ❑ WAIVER Received Soil Boring In ��}tion By Date Constructed Well Depth t2� ft COMMENTS (/ ZT(�it P1/ h' f c'vU1 r-� PE Sc Received Check Amount DatePermit] Invoice# Well ID# Codes Info B ash Remitted Service Request# 7?r� Li EHD 43-06 8/01/16 WELL/PUMP PERMIT