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WELL/PUMP PERMIT SAI4:%OAQUI .':OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 I IUIV-KEFUNDA6LE PERMIT I.HLL ,4UJ JOS-f0Uf FUR INSPEGTIUNS CArIKCJ "1 TEAR f -RUM UAIE 155UF-D ♦ Q �' p r/' JOB ADDRES JC D� 1ZJ Q � / d � CITY/ZIP Ra C.V- �i ti� / 1 .� Q'S_ CROSS STREET 2C4 �—O a k 4 APN .1 U NPARCEL SIZE "AND USE APPLICATION # OWNER NAME �(C� ip J TO C - V 0 A (PHONE i0-oC( - l (0 7 �y� OWNER ADDRESS � o x �(� � \ CITY/STATE/ZIP STogj� 7C{0 �1/ CA CONTRACTOR C 0, IA 4 PHONE 61�(r `L�t, CONTRACTOR ADDRESS L1 :�+ L v U 4- CITY/STATE/ZIP W JcCV �1J►^CrlTO C4 {? I ' C� 1 / SUBCONTRACTOR PHONE '' SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 'AAR LICENSE AC -57 ❑ C-61 1 D-09 ❑ Other NUMBER lII(: EXPIRATION DATE DOMESTIC WELL SAMPLING: i i General Mineral/Coliform Bacteria (4391) I Dibromochloropropane (4392) 1 i Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural -1 Industrial ❑ Water Quality Monitoring oil Sampling/Characterization Li Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells Soil Boring(,) 3 # of borings Geotechnical ,# of borings Ll Out -Of -Service Well ❑ Out -Of -Service Well Renewal 11 Cross -Connection Repair I I New Pump I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing Drilling Method�l/lud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth J G ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 11 Steel ❑ Plastic CI Stainless Steel ❑ Other Grout Seal Depth SD ft Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method , umped ❑ Free Fall ❑ Other 11 Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller 11 Pump Contractor ❑ Other 1 Concrete Pedestal []Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP 1� Submersibles 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. MINIMU HOU CJVA E NOTICE REQUIRED FOR INSPECCTIONSL- PLEASE CALL (209) 953-7697 SIGNED / TITLE �(-%A� Ojiy��^ hA�' ^t�� DATE K �� llflmu( E�TMENT USE NLY Date Application Accepted By �w r/ Grout Inspection By aDate 2 �d Pump Inspection By Soil Boring Inspection By COMMENTS Date Date Area Employee IDAA 1 � ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft V& m D 0 v m m ur EHD 43-06 8/01/16 "'/ U `��' WELL /PUMP PERMIT