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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT ?/ CALL 2099))953-7697 FOR INSPECTIONS EXPIRES /1 YEAR FROM DATE ISSUED JOB ADDRESSLn �� /�G4 CITY/ZIP 71 Y / ! ,? r~n CROSS STREET t8/e weH Rd� APN �1��YYY ��y) �f� PARCEL SIZ AND USE APPLICATION# OWNER NAME �r[arn/'71y I/)L5 a ch ,'�—�, PHONE C O/ 'ac�7"c..LJ 9/ y OWNER ADDRESS '/3 7 Q J • Bl"-d /l '/ fl& CITY/STATE/ZIP Trac Li CA 9s3oy CONTRACTOR ///Ne/'1�R�,/r �/ /,'�JYTT`��r'�/, / • PHO/N�E//�ss9 s/�aC�9�j0n3�1 CONTRACTOR ADDRESS f c L'?e) I.;z 3`�-C CITY/STATE/LP b �0 V/W 6/-T /O-Z3 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CIT'YISTTATE/ZIP LICENSE C-57 0 C-61 ❑D-09 0 Other NUMBER 70 a EXPIRA110N DATE aoi9 DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)C Arsenic(4393) INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural A Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization 0 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK G New Well K Replacement Well ❑Well Alteration/Modification ❑Other 0 Monitoring Wells) #of wells C Soil Bodng(s) #of borings ❑Geotechnical—#of borings 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal -1 Cross-Connection Repair ❑New Pum ❑Punip Replacement 0 PUMP Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method)I Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑Push Point C Other Proposed Well Depth FOOD ft Excavation e;?8 in diameter 0 Open Bottom W�Gravel Pack/Gravel Size X/O in diameter Conductor Casing-A%,—in diameter / Conductor Casing Depth GTO ft A10 711 s7e/,b(1n Well Casing Diameter L(Q' ckn s/Gauge/ASTM Sched 3 7S Steel 0 Plastic 0 Stainless Steel 0 Other rout Seal epth Neat Cement(94 lb bag/5-10 gal water) -9-Sand Cement 1154OW sack mix/7 gal water 1 t,� ❑Bentonite(20%solids) 0 Other S/14 CL-L/Li A� Grout Placement Method V&Pumped 0 Free Fall Other Retardant/Accelerator(name) I 4A ZPEDESTAL Installed By 0 Driller ta,Pump Contractor ❑ Other 4-6 ' IP 11 Concrete Pedestal ODimensions:Width It Length ft Thick in 0 Christy Box ❑Stove Pipe �® PUMP 0 Submersible0 Turbine 0 Other HP Pump Set ft Standing Water Level It 14Y HEREBY CERTIFY THAT I HAVE PREPARED CO NTY ORDINANCES, S ATE LLAWS HAND RULESIS ION REGULATIONS.ND THAT THE NIDA SO RK WILL OTHATNE NMYC EQUIIREDEL CI NSTH%E ✓ q 2 3 JOAQU N4?018 CURRENT AND ACTIVE W TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT Q(//N WORKERS COMPENSA WS. �F'g4 , 0NM COUH N 3 MINIMUM-24.s� �fR ADVANCE NOTICE REQUIRED FOR INSj EC IO,{N,/$QPLEASE CALL(209)953-7697 v 0FpAR M H SIGNED l� /// 'bl'T S TITLE 0A11 / / �-✓ DATE S-/a—IO EIVED v iln 2 i 2018 ENTAL HEALTH IT/SEROCES fA TMENT U E O Y Application Accepted By �4 Date Area Employee ID#jE� Grout Inspection By Dale D SPECIAL Well Permit Pump Inspection By r Date 7 WAIVER Received Soil Boring Ins ection B Date Constructed Well Depth �`� ft COMMENTS PESC Received a Amount PermiU tQ� Codes Info ash Remitted Date Service Re uest# Invoice# Well ID# " 31 EHO 43-06 8101116 \f�� e.l,'�'��.0�.+�— - C(• )Y N'� -1 t"{��'• WELL/Pu P PERMIT