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WELL/PUMP PERMIT SAN JOAQUIN COUrdrY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 �9Q5�3-7697 FOR INSPECTIONS �{-E�X-�PIIRES 1 YEAR FROM �DATE ISSUED JOB ADDRESS 25 9 0 Q � LaM fY",1P rS I��JI. CITY/ZIP 1 W"V 9 55 { / m i m JC (flet // �,• vac n CROSS STREET 1 �t APN 2y� lora' ©S PARCEL SIZE LAND USE APPLICATION# ^ ` 835 ro52..Z m OWNER NAME �O.TY`('le.Y1 �/t 1 UQ, PHONE � Cn OWNER ADDRESS ��DQO.7.t��TYImG{S �I. CITY/STATE/ZIPTY-agy. CF, 9 5-3-1-7 CONTRACTOR rO5 11nac.l-nc• PHONE CONTRACTOR ADDRESS ` CITY/STATE/ZIPM r Ar-_c+D . C-A 9 S3 Sin SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CIT �Y/STATE/ZIP (� LICENSE C-57 11 C-61 [I D-09 11 Other NUMBER 2 lO ) EXPIRATION DATE_5 G—3 LC) DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) i Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 L] New Well eplacement Well ❑ Well Alteration/Modification Ll Other 1-1MonitoringWell(s) #of wells 11 Soil Boring(s) #of borings I I Geotechnical #of borings LI Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 11 New Pump ❑ Pump Replacement ❑ Pump Repair n Raise Well Casing ♦ WELL CONSTRUCTION Drilling Method*ud Rotary ❑ Air Rotary 11 Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth2-50 ft Excavationk! in diameter ❑ Open Bottom Gravel Pack/Gravel Size3*l,in diameter I I Conductor Casing in diameter / Conductor Casing Depth F ft well Casing Diameter_ in Thickness/Gauge/ASTM Sched S F_" ❑ Steel I Plastic Il Stainless Steel F1Other Grout Seal D pth�(ft I I Neat Cement(94/b bag15-10 gal water) Sand Cement sack mix/7 gal water Bentonite(20%solids) [I Other Grout Placement Method KPumped U Free Fall 11 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By n Drillerump Contractor 11 Other 1 Concrete Pedestal I]Dimensions:Width ft Length ft Thick in ❑ Christy Box F1 Stove Pipe PUMP ❑ Submersible(-] Turbine 11 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 REQUIR FOR INSPECTIONS - PLEASE CALL (209) 953-7697Y SIGNED O ITLE r DATE 4-3® - l 18 INV It: '3N O 1R N D P RTMENT U E NL PARrMENT Application Accepted By Date l/ Area Employee ID#�" Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date 64 ❑ WAIVER Received s Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# Codes tQfO By Cash emitted Service Request# aso 9116011b P ; . I EHD 43-06 8/01/16 WELL/PUMP PERMIT