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WELL/PUMP PERMIT r ✓ 11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMyIT� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I YV C��✓� ry CITY/ZIP �(J V I GIJ ! y m / D CRO�iS STREET (40 YYI �h APN©&799 0�/(& PARCEL SIZE3j , LAND USE APPLICATION# v I �� X OWNER NAME LORI �9Adfl�5jCaOLL 121, �1� Lw � � cnn OWNER ADDRESS �/J 'E , �A A i CITY/STATE/ZIP Wl(/) . �2 CONTRACTOR //Ve i) 0 /��/SD�J � ^7�CLi 4� PHONE_2 D J 7 �J t7 - 32b CONTRACTOR ADDRESS 102- - n tli s+n A t y CITY/STATE/ZIP `75-2-7 D SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CI/TY/STATE/ZIP / ) LICENSE 12/6-57 ❑C-61 ❑D-09 El ` Other NUMBER F E--Ci t 1, ZI EXPIRATION DATE J 3/ —/ 9 DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392 Arsenic(4393) INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Gontact ame or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other # El Monitoring Well(s) #of wells ❑Soil Boring #of borings s) eotechnical_12— of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method ❑Mud Rotary [-]Air Rotary ©Auger F]Cable Tool ❑Push Point ❑ Other Proposed Well Depth IV-SO ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter F-]Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/ auge/ASTM Sched ❑Steel ❑Plastic E]Stainless Steel ❑Other Grout Seal DepthIt, - ft eat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water [:]Benton ite(20%solids) ❑Other (Grout Placement Method ❑Pumped ❑Free Fall Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller [-]Pump Contractor ❑ Other E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑ChristyBox ❑Stove Pipe PUMP ❑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 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. MI MMM 4 HO NCE NOTICE REQUIRED FOR _"INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE DATE E O H / O O N EP RTMENT USE ONLY Application Accepted By ^9 Date"0 r` ' '� Area Employee ID#� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By L )Date ❑ WAIVER Received Soil Boring Inspection By Date,/0/10/201g Constructed Well Depth fit" COMMENTS A 5 2 C!i el �` in 4illZ plpiSC� 0q, _ � u'f Y s a �lhQ/�I e0.7 fast PE Sc Received ChackAP Amount Permit/Codes Info B emitted Date Service Request# Invoice# Well ID# EHD 43-06 8/01/16 WELL/PUMP PERMIT