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WELUPUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDARLE PERMIT CALL I2n9t Q_-51-7AQ7 FflR IMCPFCTInNS FYPIRFC I YceD cone nArc lemtcn JOB ADDRESS l / l% /� CRYIZ. _ ✓ CROSS STREET �{'��'/�/V APN — 0W ARCEL SIZE / /,��J1'j0/�tU(g(� AP CATION # &er OWNER NAME �/� (%�� ^/L' YXONE 1— I OWNER ADDRESS lJ C� �CM[U.�1 r /��IJU rrY1STATE/iP /n � 2 O ea (eiav� -kIBN� I CONTRACTOR Lew CONTRACTOR ADDRESS ` CrrY/STATEMP (! I )�l'�[ l �N • 9 13 4' SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CRY/STATE/AP LICENSE ❑ C-57 C$1 n D-09 I they _Z NUMBER / EXPIRATION DATE —3141 DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) Ll Dibromochloropropane (4392) L Arsenic (4393) INTENDED USE DomeSlic/Private :I Irrigation/Agricultural n Industrial E Water Quality Monitoring n Soil Sampling/Characterization Public Water System If different from Owner. Water System Name Contact Name ar Phone Number TYPE OF WORK E New Well ❑ Replacement Well ❑ Well Alteration/Modification E Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) N of borings 7 Geotechnical # of timing' Out -Of Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair New Pum ❑ Pum Re lacement ❑ Pum Re it -I Raise Well Casing WELL CONSTRUCTION Drilling Method I Mud Rotary i Air Rotary I"1 Auger I- Cable Tool i Push Point i I Other Proposed Well Depth ft Excavation in diameter n Open Bottom ❑ Gravel Pack/Gravel Size in diameter, 0 Conductor Casing in diameter / Conductor Casing Depth ft S., Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel o Plastic n Stainless Steel n Other A/V Grout Seal Depth it n Neat Cement (94 lb bag6-10 gat water) n Sand Cement sack mixl7 g I I t Bentonite (20% solids) -1 Other Grout Placement Method ❑ Pumped Free Fall u Other 7 Retardant / Accelerator (name) PEDESTAL Installed By i Driller I Pump Contractor I Other Concrete Pedestal _Dimensions: Width ft Length ft Thick in u Christy Box L Stove Pipe PUMP -1 Submersible❑ Turbine ❑ 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 AGGOKOANGt VVIIN 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 1 AM IN COMPLIANCE WITH ALL rA m 0 z 9 PA J( 2 0 2018 IRON �N C p 1 �EAgR ov r7' �/ n.zAR HENT U�Y �,/,�/�/ Application Accepted By Date � � Area Employee ID# J��i ` "*� Grout Inspection By Date ❑ PECIAL Well Permit Pump Inspection By Date C U111, ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS EHD 4306 revised 4114118 WELL /PUMP PERMIT HEALTH !CES