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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL.H DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PEE�RMITCALL(209)953-7697 FOR INSPECTIONS EXPIRES YEAR FROM DATEISSUUED CITY/ZIP ADDRESS V m CROSS STREET APN I PARCEL SIZE LAND USE APPLICATION# 0 OWNER NAME SI r\76cn H PHONE 3 S / ^^ /- /� (��C ur OWNER ADDRESS . �� /"II(./�I�/�✓L b� �� CITY/STATE/ZIP �� ~c 1 J�� CONTRACTOR _A `LUX"v1'_�- �v-v N ✓V Al� j PHONE (�J CONTRACTOR ADDRESS 56.6- O QA'` -�` `01A+ C J --�"`� CITY/STATE/ZIPL I�A / dye cli 1796 I I SUBCONTRACTOR /�// - IAJA ,VA SUBCONTRACTOR ADDRESS /JA CITY/STATE/ZIP A 114 LICENSE A C-57 ❑ C-61 ❑ D-09 I I Other NUMBER T5g ?L 7 — EXPIRATION DATE Va � 0)oa 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 Contact Name or Phone Number TYPE OF WORK ANew Well ❑ Replacement Well El Well Alteration/Modification ❑ Other 11 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings 11 Out-Of-Service Well ❑ Out-Of-Service Well Renewal LI Cross-Connection Repair 11 New Pump ❑ Pump Replacement I I Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method 26�Mud Rotary ❑ Air Rotary a Auger ❑ Cable Tool I Push Point ❑ Other Proposed Well Depth -13406 ft Excavation 2 q in diameter I i Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter-L2�in Thickness/Gauge/ASTM Sched ' oZ SO JXSteel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth �2,ft ❑ Neat Cement(94 Ib bag/5-10 gal wafe/) Sand Cement sack mix/7 gal water LI Bentonite(20%solids) ❑ Other Grout Placement Method XPumped ❑ Free Fall ❑ Other 1-1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller XPump Contractor ❑ Other ❑ Concrete Pedestal Cl Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ 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 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 COMPENSWAIN LAWS. MINI M OUR A A CE OTICE REQUIRED FORINSPECTIONS - PLEASE CALL (209)/95 -7697 SIGNED fi TITLE V�y��f DATE D �� FN V / T p N C7. 7yF EPARTMENT USE ONLY Application Accepted By Date 4 Area lqq Employee ID� Grout Inspection By d�L�L'H f yu Date tt I ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth 3qO ft COMMENTS PE SC Received Ch Amount Date Permit/ Invoice# Well ID# Codes In o B Cash Remitted Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT