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WELL/PUMP PERMIT == ' � JLEYElj- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 53-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED Ln III JOB ADDRESS ' CITY/ZIP FScal U r, 5 x;320 m CROSS STREET �,-e4Uyl APN 2-Z9_O0y-OZ-7 PARCEL SIZE SIALAJfAND USE APPLICATION# N OWNER NAME C AG C'ec� 5�/ ��/t PHONE -36s`�j� OWNER ADDRESS 7 .7 r� CITY/STATE/ZIP i7so&h 0 A. 1 ✓/LTJ CONTRACTOR '• 1 GS�'��S rel It�Y�( � mod-II Jc�- 111 2_(h G CONTRACTOR ADDRESS I A `��l `J CITY/STATE/ZIP I� od-I l�b 0 C--i SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 'XC-57 ❑ C-61 ❑ D-09 I I Other NUMBER l6 6 NO ZZ EXPIRATION DATE DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) 11 Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private I I Irrigation/Agricultural Industrial ❑ Water Quality Monitoring 1 1 Soil Sampling/Characterization 1 Public Water System If different from Owner'. Water System Name Contact Name or Phone Number TYPE OF WORK XNew Well ❑ Replacement Well a Well Alteration/Modification 0 Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I Geotechnical #of borings ❑ Out-Of-Service Well 17 Out-Of-Service Well Renewal ! Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair I Raise Well Casing WELL CONSTRUCTION Drilling Method)KMud Rotary L Air Rotary 11 Auger I I Cable Tool LI Push Point 11 Other Proposed Well Depth ??W ft Excavation 12- in diameter I I Open BottomGravel Pack/Gravel Size in diameter I Conductyr Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 2-00 1! Steel Plastic I Stainless Steel I I Other Grout Seal Depth 2y ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water ,r,Ventonite(20%solids) ❑ Other Grout Placement Method _ umped Ll Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By CI Driller 1 I Pump Contractor I I Other I I Concrete Pedestal 1 IDimensions:Width ft Length ft Thick in r I Christy Box I i Stove Pipe PUMP _ Submersible ' Turbine I I 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. M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209 953-7697 SIGNED TITLE �V"��Q DATE/ -n C_116 WF OF 1160 III, A • - O NA IIR DN N Yq 1w:, D E P R T M, iv' T U E 0 "J L Y P�TMENT Application Accepted By Date 2/7- Area Employee ID#Ah" p Grout Inspection By 'L'1 ih r Date 4Z ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date ` Constructed Well Depth ft COMMENTS / � L .A�� 1 r PE SC Received Amount Date Permit/ Invoice# Well ID# Codes I o Bv Cash Remitted Service Request# am EHD 43-06 8/01/16 WALL/PUMP PERMIT