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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 C 1 AA Lnn JOB ADDRESS e�clh�t/' fTl CITY/ZIP SC 10 ri CG 9532 m CROSS STREET / LLJ APN-2— 'ISO-054D PARCEL SIZE`' T(IQ LAND USE AP/PLIC/ATIO�iN�#�C 0 OWNER NAME v`2 V\ r PHONE � t0► OWNER ADDRESS `CN- Se—I CITY/STATE/ZIP 'FrCd/0k\ 19 (�/ I'�QJcI� IS D 11 PHONE 5.Z'Z 1CfZU CONTRACTOR �1f`1 \�l(�J�� C ��?Y7 CONTRACTOR ADDRESSMI I A I b t� J1��.1 CITY/STATE/ZIP M aJts4 b1 C1 , SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /, LICENSE 1)<C-57 ❑ C-61 ❑ D-09 _I Other NUMBER 7- EXPIRATION DATE U-- DOMESTIC WEL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK XNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement I I Pump Repair fl Raise Well Casing WELL CONSTRU TION Drilling Method Mud Rotary ElAir Rotary I1 Auger f'❑liable Tool I I Push Point 71Other Proposed Well Depth 2 SO ft Excavation 1 y // in diameter ❑ Open Bottom )(Gravel Pack/Gravel Size in diameter CI Conduc r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter JU in �Q Thickness/Gauge/ASTM Sched a D ❑ Steel (Plastic El Stainless Steel ❑ Other Grout Seal Depth ❑ Neat Cement(94 Ib bag/5-10 gal water) H Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped L1 Free Fall ❑ Other CI Retardant/Accelerator(name) PEDESTAL Installed By n Driller I 1 Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in I I Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine 1-1 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. M48O ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED '► TITLE r DATE !�+ _,[ 01 93 01 cz jy Q N Q o V► I V, )V1t EP RTMENT UAE ONLY c r/'(qq Application Accepted By Date 10 1 Area �-c Employee ID#4WW Grout Inspection By Date la to 11 SPECIAL Well Permit Pump Inspection By Date �� D WAIVER Received Soil Boring Inspection By Date Constructed N Well,Depth ft COMMENTS t' �� C (/L« amy_ r /7X ?x— PE SC Received heck# Amount Date Permit/ Invoice# Well ID# Cod of ash Remitted Service Request# 3s$CT2 Z� -1- le' 3s-.292Mi 0-10-k W'0 uK 1 S� EHD 43-06 6/01/16 WELL/PUMP PERMIT