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WELL/PUMP PERMIT SAN JOAQUID! COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON -REFUND JOB ADDRESS CROSS STREET_ OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADI SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE -'C-57 #1 C-61 CI D-09 1-1 Other 953-711597 FOR INSPECTIONS tXF'IKtb 9 YEAR FROM DATE ISSUED _ CITY/ZIP _ r(i(_•/� WF ! L clL/ C CEL SIZE I- 54 LAND USE APPLICATION # 71c caM15)PHONE%%��/;� J/ ; nfoRt jjj CITY/STATE/ZIP L4/ ,&_,Y -j C�' qj523t_o i PHONE CITY/STATE/ZIP L 'IVI &1 /V��% ;1 %-W_/ PHO E ��/-1 ✓•2-1—* CITY/STATE/�ZInP K' �) n4 L75-� NUMBER tY EXPIRATION DATE / DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) INTENDED USE ❑ Domestic/Private VIrrigation/Agricultural LI Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charac ❑ Public Water System ��'Ne--N If different from Owner: Water System Name Contact Name or Phone Numbe TYPE OF WORK -6 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other U Monitoring Well(s) # of wells El Soil Boring(s) # of borings ❑ Geotechnical °f gdw1(7 "I Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair V JOAQUfN New Pum [I Pump Replacement El Pump Repair El Raise Well Casin ENVIRON COUNTY WELL CONSTRUCTION iERARTMENT Drilling Method Mud Rotary LiAir Rotary ElAuger ElCable Tool U Push Point 11Other Proposed Well Depth 500 ft Excavation in diameter i -i Open Bottom YGravel Pack/Gravel Size in diameter ❑ Conducto Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in T'kness/Gauge/ASTM Schad LI Steel Plastic ElStainless Steel ❑ Other Grout Seal Depth i1 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method iy(Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) (PEDESTAL Installed By LiDriller "S Pump Contractor F]Other T Concrete Pedestal ❑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. MINIMUM24 HOU CE NOTICE REQUIRED FO I SPECT( N;qPEASE CALL (209) -76 SIGNED �� TITLEDATE DEPA TMENT U E JONLY Application Accepted By Z Date % Area Employee ID# /Z46Zb Grout Inspection By Date I PE AL Well Permit Pump Inspection ByDate [1WAIVER Received Soil Boring In ec COMMENTS el Date Well Depth ft PE Codes C Amount Remitted Date A1,1 � SUBCONTRACTOR ADDRESS LICENSE -'C-57 #1 C-61 CI D-09 1-1 Other 953-711597 FOR INSPECTIONS tXF'IKtb 9 YEAR FROM DATE ISSUED _ CITY/ZIP _ r(i(_•/� WF ! L clL/ C CEL SIZE I- 54 LAND USE APPLICATION # 71c caM15)PHONE%%��/;� J/ ; nfoRt jjj CITY/STATE/ZIP L4/ ,&_,Y -j C�' qj523t_o i PHONE CITY/STATE/ZIP L 'IVI &1 /V��% ;1 %-W_/ PHO E ��/-1 ✓•2-1—* CITY/STATE/�ZInP K' �) n4 L75-� NUMBER tY EXPIRATION DATE / DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) INTENDED USE ❑ Domestic/Private VIrrigation/Agricultural LI Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charac ❑ Public Water System ��'Ne--N If different from Owner: Water System Name Contact Name or Phone Numbe TYPE OF WORK -6 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other U Monitoring Well(s) # of wells El Soil Boring(s) # of borings ❑ Geotechnical °f gdw1(7 "I Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair V JOAQUfN New Pum [I Pump Replacement El Pump Repair El Raise Well Casin ENVIRON COUNTY WELL CONSTRUCTION iERARTMENT Drilling Method Mud Rotary LiAir Rotary ElAuger ElCable Tool U Push Point 11Other Proposed Well Depth 500 ft Excavation in diameter i -i Open Bottom YGravel Pack/Gravel Size in diameter ❑ Conducto Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in T'kness/Gauge/ASTM Schad LI Steel Plastic ElStainless Steel ❑ Other Grout Seal Depth i1 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method iy(Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) (PEDESTAL Installed By LiDriller "S Pump Contractor F]Other T Concrete Pedestal ❑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. MINIMUM24 HOU CE NOTICE REQUIRED FO I SPECT( N;qPEASE CALL (209) -76 SIGNED �� TITLEDATE DEPA TMENT U E JONLY Application Accepted By Z Date % Area Employee ID# /Z46Zb Grout Inspection By Date I PE AL Well Permit Pump Inspection ByDate [1WAIVER Received Soil Boring In ec COMMENTS el Date Well Depth ft PE Codes SC Received � _ Info B Cash Amount Remitted Date Permit/ Invoice # Well ID# Service Request # ,M ci I � U 3 cI IS ZOfV Ua -v 05-o z l 2c) i o a EHD43-06 8/01/16 WELL/PUMP PERMIT