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WELL/PUMP PERMIT 10 1 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 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / l7 CITY/ZIP �(' �/ ' (,� X221 N m CROSS STREET V11A 6 G APN 0(/ '1 � / �1 6 PARCEL SIZE _LAND USE APPLICATION# o L {{ '7 m En OWNER NAME (7 /� L PHONE 17", '—ff 9 ?—XS 7 OWNER ADDRESS ISO)l O [ l f O rj Jk t)PfS C CITY/STATE/ZIP 40AA.1 �r L" F�� C.L( /!60 CONTRACTOR /4 �j�t, , P. y HONE �� Sy CONTRACTOR ADDRESS PL) C CITY/STATE/ZIPC/7/ a� ar.1 C/ SUBCONTRACTOR t?tAJ AdT PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 'C LICENSE -57 El C-61 ❑D-09 El Other NUMBER 3 / 3? EXPIRATION DATE DOMESTIC WELL SAMPLING:[-]General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private <Irrigation/Agricultural [:]Industrial ❑Water Quality Monitoring [:]Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Uontact Name or Phone Number TYPE OF WORK QNew Well ❑Replacement Well ❑Well Alteration/Modification El Other El Monitoring Well(s) #of wells ❑Soil Boring #of borings s) E]Geotechnical #of borings F1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair -J�jjllew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method+<fMud Rotary El Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other Proposed Well Depth ft Excavation — in diameter ❑Open Bottom N<13ravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter/p in Thickness/Gauge/ASTM Sched :Z 0 (Z ❑Steel '-<lastic [-)Stainless Steel ❑Other Grout Seal Depth j;� b aft ❑Neat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Metho Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller El Pump Contractor ❑ Other E]Concrete Pedestal Fpimensions:Width—�ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP pj�2,3ubmersible❑Turbine ❑Other HP Z Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT 1 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED 6� �/�J ,.� TITLE Q DATE �— "N 1 Sm JdAQUIN C UNTY E NV RC NIV EN DEPARTMENT USE ONLY Application Accepted By I Date_ < 'tt�7 Area �' C Employee ID# (-J r n Grout Inspection By _ Date 1 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth S 3 ft COMMENTS PE SC Received Check#I Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# X13 o 3 ) ra a5 Njfd U st) '3 `L o0 EHD 43-06 8/01/16 WELL/PUMP PERMIT