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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 Q A I L//'' rn JOB ADDRESS 2 8 L4�Z L A Awov\ t CITY/ZIP ;Fj- t o K q m n (� D CROSS STREET t\ -1#,r6A CJ� - Lp' APN 2�'1��d `� PARCEL SIZEd�r/16 LAND USE APPLICATION# OWNER NAME Sere l l Ay i I ti PHONE 60-7-:9916 N OWNER ADDRESS Z�414 —, r eyMw^ /�� CITY/STATE/ZIP16�CAA`A CONTRACTOR ,Yl 1 � 1 Lf+'l 1 1�� h�' PHONE 1 /'jg2;8 CONTRACTOR ADDRESS l�q A l►,ees 1� 'l _____ CITY/STATE/ZIP/�f�/�J e S 7 40 i (_� ISM SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE A C-57 I i C-61 I D-09 I I Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibrornochloropropane (4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural I_! Industrial I 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 ew Well IReplacement Well Li Well Alteration/Modification I Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump I I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary Air Rotary E Auger I; Cable Tool 1 Push Point Other Proposed Well Depth_ Excavation ��_tA diameter I; Open Bottom Gravel Pack/Gravel Size in diameter I I Conductoj Casing in diameter / Conductor Casing Depth ft Well Casing Diameter fo in-- Thickne2ss/Gauge/ASTM Sched�. I I Steel lastic I I Stainless Steel I I Other Grout Seal Depth�ft-4 ❑ Neat Cement(94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other _ Grout Placement Metho umped tl Free Fall 1 Other 1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 11 Other !-I Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in Christy Box I Stove P�Ipe�] PUMP Submersible[] Turbine I1 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. MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOfR�INSPgCTIONS -PLEASE CALL (209)) 953-769`7Q SIGNED a, 1 TITLE /w' DATENJ A D P T M E N T U E ONLY Application Accepted By c Date Area Employee ID#�� Grout Inspection By Date CI SPECIAL Well Permit Pump Inspection By Date 1-1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS �,'r � aL "146 1A) �ttCt— • i PE SC Received Check#/ Amount Permit/ Code fo By emitted Date Service Request# Invoice# Well ID# �1A-4'gel EHD 43-06 8/01/16 WELL!PUMP PERMIT