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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 IYE{XPI/FRES1YEAR FROM DATE ISSUED JOBADDRESSr/'I SaIt'hIY CiTY/ZIP Sir lk �"rnl IJ (r06 CROSS STREET A )(,-1rQ4 ly ill /Sr APN i & 0 /:' DZ 7 PARCEL SIZE � LAND USE APPLICATION # OWNER NAME 11; "r M L y t: %, `o Me u) OWNER ADDRESS go {ry-' `�\) (d ✓) K a r✓Yl t+ / A� CITY/STATE21P Me (A! L/ r C�y CONTRACTOR K ( ii,i h Cv f&r- [A{-� /�^ /' S yy�� PHONE /9 `+ CONTRACTOR ADDRESS GVot /W— (1 ,(N�V^• t Rd. Ae ' / iTY/STATE/LP � ` q1vt �j SUBCONTRACTOR • -1- yr '7 tr,,r - jj W C PHONE ' A� 1 SUBCONTRACTOR ADDRESS LlY hA- �I Tur V CITYISTATE/7JP G1`1 Pr.I tp LICENSE V/C-57 ❑ C-61 ❑ D-09 ❑Other NUMBER � v � EXPIRATION DATE DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) ❑ Arsenic (4393) NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural a Industrial ❑ Water Quality Monitoring-40toil Sampling/Characterization ❑ Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK I New Well D Replacement Well D Well Alteration/Modification ❑ Other Monitoring Well(s) # of wells D Soil Bodng(s) # of bodngs -J Geotechnical _# of borings ❑ Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method I Mud Rotary ❑ Air Rotary ❑ Auger D Cable Tool D Push Point ❑ Other Proposed Well Depth-ro 0_ft Excavation in diameter Open Bottom D Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Schad Steel Ll Plastic D Stainless Steel ❑ Other Grout Seal Depth ft j Neat Cement (94 /b bag15-10 gal water) ❑ Sand Cement sack mixll gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall - Other D Retardant / Accelerator (name) PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other ❑ 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. MM7R ADVANCE NOTICE REQUIRED FO`//R I/N�S /ICTIONSy�- PLEE.A�S,r�E CALL (209)9r3-7.697 SIGNED f TITLE' ''t r 1 L 1e7 1 / [ 4CiY DATE v Application Accepted By Grout Inspection By Pump Inspection By Soil Baring Inspection By COMMENTS DEPARTMENT USE ONLY % DateU' / Date Z Date Date Area I ISt,cn Employee ID# h �C ❑ SPECIAL Well Permit F1 WAIVER Received Constructed Well Depth ft PESC Codes Received Check#/ Info B Cash Amount Date Permit/ Invoice # Well ID# Remitted Service Request # EHD 43-06 --d 4114/18 WELL /PUMP PERMIT