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WELL/PUMP PERMIT SAN JOAQUIN.n0+O'�NTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON,,:R �_FONDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln JOB ADDRESS �� CITY/ZIP m � M �- n r 9,4 C �J CROSS STREETf, . APN Z3I��C•,DO -T V 5 PARCEL SIZE7_9.(v8 LAND USE APPLICATION# � OWNER NAME ' RAW a 1 PHONE ZI (7-7(r p OWNER ADDRESS O W . L`irmc CITY/STATE/ZIP-'"ra►Cv _ cA9 C3�04 CONTRACTOR �\ O• Y PHONE '5 45— 1 18✓ CONTRACTOR ADDRESS L. j CITY/STATE/ZIP m O d c_-4cll CFS q3 56 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 [_1C-61 11D-09 ❑ Other NUMBER�, /nA 13 EXPIRATION DATE Ei ow DoMesTlc WELL SAMPLING:' General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 1.1 Industrial f I Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ 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 I I Geotechnical #of borings ❑ Out-Of-Service Well Cl Out-Of-Service Well Renewal LI Cross-Connection Repair I.] New Pump ❑ Pump Replacement a Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method yMud Rotary ❑ Air Rotary a Auger ❑ Cable Tool f_l Push Point ❑ Other Proposed Well Depth2—IM ft Excavation ILk _ in diameter I I Open Bottom ravel Pack/Gravel Size_in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched�j I I Steel f lastic ❑ Stainless Steel P. Other Grout Seal Depth _ft r_I Neat Cement(94 lb bag/5-10 gal wate/) L Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other Grout Placement Method Pumped i l Free Fall 17 Other 1-1 Retardant/Accelerator(name) PEDESTAL Installed By Cl Driller X Pump Contractor f_I Other ❑ Concrete Pedestal f_1Di ensions: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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)C953-7697 SIGNED 6 TITLE u 1 DATE F F EPARTIMENT USE ONLY W�/7 Application Accepted By I- at J'25 — � '� Area a z Employee ID#/4 h/Xt Grout Inspection By: a eU -+ jS[Ij Ll Well Permit Pump Inspection By Date F1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS J ' 'a c�J Vt PE SC Received heck Amount Permit/ Codes Info B sh Remitted Date Service Request# Invoice# Well ID# 43 C 1� 2k W 20 343-33,11) F HD 43-06 8/01116 WELL/PUMP PERMIT