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WELL/PUMP PERMIT SAN JOAQUIP!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 Ln JOB ADDRESS (I I CITY/ZIP m D CROSS STREET APN o I z Uo PARCEL SIZE I S D LAND USE APPLICATION# n ,,7C� p OWNER NAME I r !1 'PHONE —1!(Y ' C •; I �? OWNER ADDRESS �lJ UX Cl CITY/STATE/ZIP L4keUA-j qrp— 34-o CONTRACTOR "'{ jr[] � � PHONE CONTRACTOR ADDRESS _r CITY/STATE/ZIP , Of SUBCONTRACTOR ' �-1 ✓S•PHONE �• 434 SUBCONTRACTOR ADDRESS CITY/STATEIZIIPP LICENSE C-57 )'IC-61 Ll D-09 I 1 Other NUMBER tY EXPIRATION DATE / DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE ❑ Domestic/Private Irrigation/Agricultural LI Industrial LI Water Quality Monitoring LI Soil Sampling/Characa mr ❑ Public Water System . If different from Owner: Water System Name Contact Name or Phone NumbeF 1k1ZVLC1 TYPE OF WORK I New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ g #of borings ❑ of g Soil Boring(s) Geotechnical Q' 'Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair JOAQU1 New Pum ❑ Pum Replacement ❑ Pum Repair ti Raise Well CasingE RON N 0A10-90Y WELL CONSTRUCTION 11 PARTMENT Drilling Method)(Mud Rotary F1 Air Rotary F1 Auger ❑ Cable Tool 11 Push Point 1i Other Proposed Well Depth50ft Excavation _ in diameter I I Open Bottom YGravel Pack/Gravel Size VA in diameter ❑ Conducto Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in T'kness/Gauge/ASTM Sched ❑ Steel Plastic I I Stainless Steel ❑ Other Grout Seal Depth ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ryXPumped ❑ Free Fall ❑ Other 1_I Retardant/Accelerator(name) PEDESTAL Installed By Cl Driller Pump Contractor ❑ Other Concrete Pedestal F1 Dimensions: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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM HOU NCE NOTICE REQUIRED FO I SPECTI NS -PLEASE CALL (209) och-7607 SIGNED TITLE AJ DATE oft i X Ir i i DEPA TMENT U E JONLY Application Accepted By Date / Area Employee ID# 0694Y. Grout Inspection By Date Ll PE AL Well Permit Pump Inspection By Date IJ WAIVER Received Soil Boring In pection By Date Con/�tructed Well Depth ft COMMENTS tel` 401 a1,Sh✓iGc . SCP A.ZAw PE SC Received ( Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# 436 LI � � I � q 112211 EHD 43-06 8/01/16 WELL/PUMP PERMIT