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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUES STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT -+(CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ' OS�11 S, �?►{ II3 i� CITY/ZIP m '� 1 ` I ,i D CROSS STREET] 1�\h ICSH^rAPN 0 fj {3�r` {�y� PARCEL SIZE LAND USE APPLICATION# OWNER NAMEr�+N 1/ S It✓I �R'_`�"T P P< PHONE � C^� 6,z 2l OWNER ADDRESScn 1 V C/ T L>k l�c:� �V r J CITY/STATE/ZIP FNS�S� r i �� I S✓�G CONTRACTORMy�ee S 1 I f A I �r 1I �LV{ h�• P�HONE \ CONTRACTOR ADDRESS i F d S CITY/STATE/ZIP r/�Wdf� ,t 0, 4�7c35C 1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS tri y LICENSE C-57 ❑ C-61 Ll D-09 Ci Other NUMBER'/ib$�L�Z EXPIRATION DATE `/ -3 G DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE _.Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring tJ Soil Sampling/Characterization F 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 ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 1.1 Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal Fi Cross-Connection Repair ❑ New Pump U Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method)<Mud Rotary ❑ Air Rotary Ll Auger D Cable Tool iI Push Point IJ Other Proposed Well Depth 2 Q ft Excavation -L-- in diameter I I Open Bottom 'Gravel Pack/Gravel Size in diameter L Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched_7(7-6 1 1 Steel XPlastic L Stainless Steel Il Other Grout Seal Depth /!3 r� ft ❑ Neat Cement(94 lb bag/540 gal water) [1 Sand Cement sack mix17 gal water Bentonite(20%solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall 11 Other _ _ !i Retardant/Accelerator(name) PEDESTAL Installed By Ll Driller f_I Pump Contractor 1 Other n Concrete Pedestal ❑Dimensions:Width___ft Len th ft Thick in IJ Christy Box n Stove Pipe (PUMP ❑ Submersible❑ Turbine IJ 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED d��- TITLE rl��f DATE t t:i U � NVAC N ENTAL ro EP�RTMENT U E NLLY Application Accepted By Date �[/ Area t Employee ID#� Grout Inspection ByIq Cl O�V1t/1 C1!y1��lR—Date / t SPECiHL Well F�errrl: Pump Inspection By Date 1-1 WAIVER Received Soil Boring Inspection By ate Constructed Well epth _� _ft COMMENTS t L t SI !' PE SC Received Check#/ Amount PermiU Cod I o B Cash emitted Date Service Re uest# Invoice# Well ID# EHD 4M6 8/01/16 WELL/PUMP PERMIT