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d, WELUPUMP PERMIT P `' 40 SAN J('j,1!OUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN, 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 t [JON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES ') YEAR FROM DATE ISSUED JOB ADDRESS ( � CITY/ZIP o m D CROSS STREET `� �� APN 6 J�l PARCEL SIZE? j, LAND USE APPLICATION# OWNER NAME HONE j-- Ll" m nn ^� N OWNER ADDRESS CITY/STATE/ZIPT� CONTRACTOR PHONES i , �l CONTRACTOR ADDRESS / u' /d'AT / CITY/STATE/ZIP SUBCONTRACTOR !C E3l, �� " 1r L��'fA PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE IWI" C-57 ❑ C-61 Cl D-09 CI Other NUMBER —.7% M1� i EXPIRATION DATE DOMESTIC WELL SAMPLING: ! General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) I Arsenic(4393) INTENDED USE ❑ Domestic/Private` Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK`A<New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ew Pump Cl Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRU TION Drilling Method ,;,�9Vlud Rotary ❑ Air Rotary ❑ Auger Cable Tool 1_1 Push Point ❑ Other Proposed Well Depth d ' � _ft Excavation in diameter ❑ Open Bottom gravel Pack/Gravel Size in diameter ❑ Conducjpf Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched-l-P I I Steel )<Plastic ❑ Stainl .lSteel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ,Sand Cement �' sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method+ePumped ❑ Free Fall 11 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By,.Q Driller ❑ Pump Contractor ❑ Other Concrete Pedestal L1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ,i ubmersible❑ Turbine ❑ Other HP_2A2_ 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 LiCEN. E IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 UR D, NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED ✓� �; TITLE DATE LL DEPARTMENT U5E Gid LY SAN JOfacy4 pt Application Accepted By Date 2 (❑ Area kl ELI��&,�I vim Grout Inspection By V� Date ❑ SPECIAL Well 1'� Tf9FNT Pump Inspection By � Date ❑ WAIVER Received/, Soil Boring Inspection By Date Constr, ted Wel Pt In ` �" ft COMMENTS �i-ti:i45?�Y t7y't'wt� 5 ��1' t PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT