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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 EXPIRES 1 YEAR FROM DATE ISSUED TI JOB ADDRESS CITY/ZIP i (14 L m 004 In� ¢ CROSS STREET _ P N d� U I PARCEL SIZE 1 LAND U E APPLICATION# /��j�j A M .^ qq G� / r J ✓�o� m OWNER NAME M N! US CD I PHONE I i OWNER ADDRESS // V CITY/STATE/ZIP CONTRACTOR PHO I (?,3/- 1[� CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR A rl PHONE III SUBCONTRACT ADDRESS aa�� ' _ LICENSE 57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE -/ DOMESTICP� 0 L SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 1_1 Industrial Li Water Quality Monitoring ❑ Soil Sampling/Characterization 0 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service ell ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 11 New Pump Pump Replacement 11 Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ 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 11 Steel ❑ Plastic ❑ Stainless Steel ❑ Other Gro,it Seal Depth ft [1 Neat Cement(94 lb bag/5-10 gal water) [I Sand Cement sack mix/7 gal water El Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor CI Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine F1 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 OMPENSATION LAWS. I 2ANCE NOTICE REQUIRED FO SPEC IONS - PLEASE CALL (209) 953 7697 SIGNED VVW TITLE DATE yj A �CA Mm LT N R DEPARTMENT USE ONLY Application Accepted By Date J I Area S Employee ID# 11�P Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By u Date Q ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ec Amount Permit/ Codes Info B ash Remitted Date Service Request# Invoice# Well ID# 3 2 EHD 43-06 8/01/16 WELL/PUMP PERMIT