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/� ✓ lo-, 1�'3o WELL/PUMP PERMIT b-dT,-K'4' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 N_QN-REFUNDABLE ^�PERMIT / CALL 2019 953-769 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �(� ,� y� i�F��`� d in TQ, CITY/ZIP ��rr1X r �� Z� m ti D CROSS STREET APN �'403" PARCEL SIZEfi.0LAND USE APPLICATION# A s q�7m OWNER NAME V k, IVL- PHONE �eJ /" .u) I (n OWNER ADDRESS Zt711-41 M{A?� / L S 4-Q-lft) CITY/STATE/ZIP l' CONTRACTORl `Q � ♦�� r�'LJGf[t t!� .nPHONE �Z_A CONTRACTOR ADDRESS ' `� /y�1 / 1�Ly CITY/STATE/ZIP j *(/Q� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / y LICENSE C-57 El C-61 r-1 D-09 ❑Other NUMBER 6 a$ (C�ZL EXPIRATION DATE L �/ DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial E]Water Quality Monitoring El Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK Aew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑ #of borings SoilBoring(s) ❑Geotechnical #of borings F1 Out-Of-Service Well []Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair [-]Raise Well Casing WELL CONSTRUCTION Drilling MethodMud Rotary ❑Air ❑Auger ❑Cable Tool ❑Push Point ElOther Proposed Well E]Con�i� xcavation 12 in diameter ❑Open Bottom ';Gravel Pack/Gravel Size in diameter ❑Conduct asing in diameter / Conductor Casing Depth / \ ft Well Casing Diameter in Th')rNeattgCement /Ge/ASTM Schede ❑Steel Plastic El Stainless Steel ❑Other Grout Seal Depth (94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water fi4tentonite(20%solids) Other Grout Placement Method Murnped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other El Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible❑Turbine ❑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 � p,� j p l SIGNED V1 G K d-r-ei1 's, TITLE k-tili, DATE �Y" .2 1 -7 I 1 A N R U � ►' R 1 D PARTM ENT USE NLY Hppucauon mccepfed by nate �l/� e _ recd cr.,;j,vyae iLr� Grout Inspection By Date kSPECIAL Well Permit L Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date ns ctga Well Depth ft C MMENTS — r LA PE Sc Received Amount Permit/ Codes Mfo By Cash emitted to Service Request# Invoice# Well ID# l ry 6 3 8 E9 EHD 43-06 8/01/16 4?` 1' e�r 4;�f rY� 1;;®w wm // K(.q� d?e ch ) LL/PUMP PERMIT