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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 PE RMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE(ISSUED JOB ADDRESS - CITY/ZIP Y) v m -� / �L/�'� PPARCEL SIZE A CROSS STREET I A �J Iy�LAND USE PPLICATIO # v 017 m OWNER NAME �7 V VFX 1�""'"�— PHONE OWNER ADDRESS 7, CITY/STATE/ZIP CONTRACTOR 04 J__ fati� PHONE � 2 � CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR , a.�s LJY) PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 1<1C-57 ❑C-61 ❑D-09 ❑Other NUMBER C t EXPIRATION DATE DOMESTIC WELL SAMPLING:,KGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sam pling/Characteriza'n ❑Public Water System If different from Owner: Water System Name uontaGt Name or Phone Number TYPE OF WORK `Slew Well ❑Replacement Well ❑Well Alteration/Modification El Other El Monitoring Well(s) #of wells E]Soil Boring #of borings s) El Geotechnical • �,►�in b �6 �01� ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑ p Cross-Connection Re air ew Pum El Pump Replacement El Pump Repair E]Raise Well CasingE J�'gQU! WELL CONSTRUCTION PIFALjN O ENr'W I Drilling Method�ud Rotary El Air Rotary ❑Auger ❑Cable Tool ❑Push Point El Other Ep'4RNscE r Proposed Well Depth-1 y ft Excavation in diameter E]Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched J_?_0 ❑Steel><Plastic ❑Stainless Steel ❑Other Grout Seal Depthft ❑Neat Cement(94 Ib bag/5-10 gal water) [wand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Metho>&Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Killer E]Pump Contractor ❑ Other E]Concrete Pedestal EDimensions:Width ft Length ft Thick in ❑Christy Box E]Stove Pipe�:__] PUMP ❑Submersibl' Urbine ❑Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREFARED THIS APPLICATION AND THPT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. ' 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 OU AD NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 f� SIGNED /`/AL"/� f!?i. TITLE �J /✓ DATE v En O T Ilk Aii C` 'J' T I v y v i Application Accepted By Date o I Area Employee ID# Grout Inspection By Date [-] SPECIAL Well Permit ;ft"-4,Pump Inspection By /hTI' Pbate ❑ WAIVER Received( Soil Boring Inspection B Date r/ Constructed Well Depth 3y ft COMMENTS O Y ry+ rrw L PE SC lRecery d hec Amou U Perrft Codes Info B ash Remitted Date ryice Request# Invoice# Well ID# 4- b 777 1 `' WKW / 60 1 4 EHD 43-06 8/01/16 WELL/PUMP PERMIT