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J l 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 EXPIRES 1 YEAR FROM DATE ISSUED 9 / l JOB ADDRESSjII � CITY/ZIP Wu ) p/ � CSC I✓� m CROSS STREET r h ti.)��t6 P- ' APN�Q/ - 010 0 ✓�yVySy PARCEL SIZE�1__j D USE APPLICATION#p 7p OWNER NAME �1UU�\-7 �' „ '� � tAt �l r !"� PHONE (:3LDq�—/ ��1 S �J / M OWNER ADDRESS �o / G�lr.� CITY/STATE/ZIP -✓ � � CONTRACTOR la- 'i* ) /L j aPt D PHONE CONTRACTOR ADDRESS 5b5_F0Akr00JP 1P-C- , CITY/STATE/ZIP b)ei rse,spa /9orS,� SUBCONTRACTOR /VA �/ PHONE /(J / 4 SUBCONTRACTOR ADDRESS UA CITY/STATE/ZIP AIA LICENSE C-57 ❑ C-61 ti D-09 I Other NUMBER /✓ EXPIRATION DATE 6 � DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private PQ rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification I-1 Other ❑\Monitoring Well(s) #of wells [ISoil Boring(s) #of borings _1Geotechnical a of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement F1 Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method,)(Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 6 ft Excavation c'�t,cS in diameter ❑ Open Bottom AGravel Pack/Gravel Sizeyf),, in diameter ❑ Conductor Casing VA in diameter / Conductor CaasingDepth A ft Well Casing Diameter, in Thickness/Gauge/ASTM Sched .d,J� Steel 1 Plastic 11 Stainless Steel ❑ Other Grout Seal Depth �L) ft ,Neat Cement(94 Ib bag/5-10 gal wate/) Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method_XPumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By Li Driller Pump Contractor ❑ Other ❑ Concrete Pedestal UDime sions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP [I Submersible❑ Turbine n 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. MINIMUM 24 H DVANgE NOTICE REQUIRED FOR INSPEQC�T.-I-ONS - PLEASE CALL (209) 953-7697 SIGNED TITLE `��v DATE 51j� Of 7 A V/ N C F N D E P ARTMENT USE ON LY 1 Application Accepted By Date � :-o-d Area I C Employee ID# A h Grout Inspection By :!�rL. Date 'i' 17-11141 IJ SPECIAL Well Permit Pump Inspection By Date I I WAIVER Received Soil Boring spection By Date Constructed Well Depth ft COMMENTS 17(?,11't PE SC Received heck Amount Date Permit/ Invoice# Well ID# Codes Info B sh Remitted pService Request# �YJ U EHD 43-06 8/01/16 WELL/PUMP PERMIT