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WELL/PUMP PERMIT SAN JOACIUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NOWREFUND P IT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSCITY/ZIP Al I � 2 3 / _ m CROSS STREET APN �C , PARCEL SIZE, LAND USE APPLICATION# LJ A OWNER NAME LLCI�[ ^ PHONE OWNER ADDRESS /�;vs sbo O m f�ILC/ CITY/STATE/ZIP Cna/L_ 7 n 'f . �r_ CONTRACTOR i - asPHONE J J ! - G ! w CONTRACTOR ADDRESS 6 CITY/STATE/ZIP SUBCONTRACTOR elmr'7r7Y �� '<� �• PHONE 2'2— SUBCONTRACTOR ADDRESS,4t-57CITY/STATE,/yZIIP / LICENSE -57 F1 C-61 ❑ D-09 r I Other NUMBER V )'7-3&t: EXPIRATION DATE 6 G q DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE H Domestic/Private I.-i rrigation/Agricultural 11 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization [I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK bFg'-New Well ❑ Replacement Well I I Well Alteration/Modification 11 Other CI Monitoring Well(s) #of wells 11 Soil Boring(s) #of borings Ll Geotechnical #of borings Ll Out-Of-Service Well Li Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump ❑ Pump Replacement ❑ Pump Repair I I Raise Well Casing WELL CONSTRUCTION Drilling Methodm4 Mud Rotary ❑ Air Rotary CI Auger ❑ Cable Tool CI Push Point ❑ Other Proposed Well Depth�ft Excavation 1,V in diameter L Open Bottom -+eGravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter- in Thickness/Gauge/ASTM Schede I_I Steel Plastic ❑ Stainless Steel F1Other Grout Seal Depth ` ft .1Neat Cement(94 lb ba75-10 gal water) ie Sand Cement ��; sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method*�Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By NOriller CI Pump Contractor I I Other 11 Concrete Pedestal F]Dimensions:Width: _ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HPA-F) 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. MMIINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED,C MS TITLE - - 4DATE �— 4 -7777 L I PA 1 tl _LJ V 3� H LH EAT EN �. DEPARTMENT USE ONLY Application Accepted By Date / Area t✓ 'c7 Employee ID#'\ Grout Inspection By Date S' / ❑ SPECI L Well Permit Pump Inspection By c� C Date 0 5? l ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth J�U ft COMMENTS - CC l 1�� fn -r--f' i — h'rL_-jj ' `' PE Sc Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 1 t'Jq 34 "' 2- L'�sg IWP63 EHD 43-06 8/01/16 WELL/PUMP PERMIT