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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 E PIRES 1 YEAR FROM DATE ISSUED r—AJOB ADDRESS kw-cOnrlCITY/ZIP m 11 CROSS STREET I✓ Q 1 PARCEL SIZE-7—L AND USE APPLICATION# v OWNER NAME D �1 PHON /� n )a SA CA OWNER ADDRESS7Q Id IJ �J�CITY/STATE/ZI CONTRACTOR i PHONE�I/ / CONTRACTOR ADDRESS CITY/STATE/ZIPC�� _( SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS 4Y/STATE/ZIP /�j/ LICENSE C-57 11C-61 [ID-09 F1 Other NUMBER I EXPIRATION DATE ✓/ r DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private VIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 1_I Soil Sampling/Characterization ❑ Public Water System PaV•a...._ If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK Li New Well Replacement Well ❑ Well Alteration/Modification LI Other I 1 Monitoring Well(s) #of wells 1 I Soil Boring(s) #of borings I_I Geotechnical #Iq I gb Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 9 2018 ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing 3ANJ0q WELL CONSTRUCTIONROIVME q� Drilling Method IL Mud Rotary ❑ Air Rotary n Auger Ll Cable Tool IJ Push Point ❑ Other HEALTHI)Ep'gTALRT Proposed Well Depth GIZ,' ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size,6,46 4,Giameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 10 in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic i I Stainless Steel ❑ Other Grout Seal nepth.! 5-0 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other Cl Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller t% Pump Contractor CI Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box El Stove Pipe PUMP 714: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 ORD ANCES, 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 COMPEN ON LAWS. MINI RLADVANCE NOTICE REQUIRED FOR INSPECTI NS -PLEASE CALL (209) 953-7697Ile (, SIGNED , / T TLE DATE Q l� i D/E TMENT USE /ONLY Application Accepted By Date Area Employee ID# Grout Inspection By / Date PECIAL Well Permit Pump Inspection By Date 1 1 WAIVER Received (� Soil Boring In tion By Date Constructed Well Depth t t2 ft COMMENTS ,7 ��i/I� !21122 PE Sc Received Check Amount Date Permit/ Invoice# Well ID# Codes Info BYA sh Remitted Service Request# ? a3 71_71T EHD 43-06 8/01116 WELL/PUMP PERMIT