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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED C1 t'n JOB ADDRESS ?�B-1-1 6- U165ma t1 ��. CITY/ZIP lro �V C1C7 m `, , �j D CROSS STREET • OAr F W.L:lnY1t 'A`P-N2S3 —220-0 S PARCEL SIZE 15.1 LAND USE APPLICATION# A OWNER NAME Moor C �O►YCTTS� }PHONE -(ziSN oII1e �? OWNER ADDRESS . � r'r\5 MQ_'rN CITY/STATE/ZIP \ rte,C�I �T 1 as 3 day CONTRACTOR t-oS• l C. PHONE CONTRACTOR ADDRESS CA':Q {� CITY/STATE/ZIP oc�ems}r� A 5 3S1(6 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP c LICENSE C-57 f 1 C-61 ❑ D-09 I I Other NUMBER 29 O b Ayj EXPIRATION DATE J DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) ' Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 1 1 Industrial ❑ Water Quality Monitoring ii Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORKNew Well ❑ Replacement Well 11Well Alteration/Modification ❑ Other Cl Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 1 Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method)(Mud Rotary ❑ tary ❑ Auger IJ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ExcavationJ� in diameter ❑ Open Bottom Y Gravel Pack/Gravel Size�(o in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter,-B- in �Thiicck-nfess/ /ASTM Sched SQ'�(p_ [I Steel Plastic [I Stainless Steel ❑ Other Grout Seal Depth �e-4D 7_ , t ement(94 lb bag/5-10 gal water) [1 Sand Cement sack n7ix17 gal water Bentonite(20%solids) iJ Wer Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller I I Pump Contractor CI Other Cl Concrete Pedestal Li 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 24 HOUR ADVANCE NOTICE REQU FOR\I'NSPECTIONS - PLEASE CALL (209) 953-769Q7 SIGNED y ITLE �L �• DATE rz Q EP RTMENT U E NL E Application Accepted By Date Area Employee 04AW10 Grout Inspection By MIf�Date Ll SPECIAL Well PeCl111t Pump Inspection By Date L] WAIVER Received Soil F3oring Ins e^tion By _ Pale Constructed Well Depth ft COMMENTS 17 PE SC Received Check#/ Amount Permit/ ' Codes fo B Cash Remitted Date Service Request# Invoice# L Well ID# 'Ab .2 ;�-9 7 c EHD 43-06 8/01/16 WELL/PUMP PERMIT