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Spo S0LVg1AQ WELL/PUMP PERMIT SAN JOActum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 NON-REFUNDABLE PERMIT PRMIT G GALL /LUV- IV04-101\x/ FOR INSPECTIONS 1/ MAI'l •tw I T tAK I'KUM WA h ISSUEU JOBADDRESS r�G `Qk ! , Ul%/f-1 "rIYVu CITY/LP 101fI. / `C. -I r / CROSS STREET i9)7#( ¢t .� J"�'.��ZYyA, ®�� APN //�{� �'7�'�1 iy v�1 PARCEL SIZE V LAND USE APPLICATION # OWNERNAME �r YC/(.tAACN' <t//�✓ �(l�L�j )f `-�'- ��PyHO/N�E(�Y�Z/,Sy/�� /�-7 /,7.//1�� OWNER ADDRESS &�W �'4 '� • e r �- r I �" CITY/STATEZP � r'V • / r ' fab r -� f WS63 CONTRACTOR l / VW l�j�/G✓G✓f�S j��/PHONE 152 �—CO�(I'm CONTRACTOR ADDRESS ,O ` yS/ T'-^+ �r r"� '/l CrrY/STATEMP ACTOR ADDRESS Crry//STATEEZP '4C-57 )C-61 ❑ D-09 11Other NUMBER I4 ! I(9/0 ExPIRATION DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System It different from Owner Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification L1 Other ❑ Monitoring Wells) # of wells ❑ Soil Boring(s) If of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair `r eNAW Pumn n Pumo Replacement fl Pumo Repair ❑ Raise Well Casino Drilling Method n Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool F Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel G Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (941b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped F Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal oDimenslons: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersibles Turbine 11 Other HP Pump Set '�✓ It 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 W%THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS C ENSATION 1.LAWS. W '/74P -HOU ADVA//NC_ E NOTICE REQUIRED FOR IN //PE�Cj/TIONS - PLEASE CALL (209)l1553-76697 y) SIGNED • 1 4 'f. TITLE �" W� DATE Application Accepted By, Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS MENT USE ONLY Date Date ► Date��^, 11 Date Constructed Well Depth ft Area 3 f c> � Employee ID# 11SPECIAL Well Permit / ❑ WAIVER Received EHD43-08 mvised4/14118 WELL/PUMP PERMIT