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S" UUELUPUMP PERMIT F✓ SA0 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE P RMIT CALL 209 953-76697 Fo SPECTIONS ,,EXPIRES 1/YEAR FROM DATE ISSUED .;OB ADDRESS /� G-�' CITY/ZIP t_t C /✓ I � m J l D CROSS STREET I APN �� >��c,`7 PARCEL SIZE LAND USE APPLICATION## OWNER NAME G '�C. LI /v1 PHONE 1 V f J /U40 OWNER ADDRESS CITY/STATE/ZIP � CONTRACTOR l�I-�`�`� L� !�`1 PHONE %J L u V y^i CONTRACTOR ADDRESS y�A L—2(] ` P�nw CA CITY/STATE/ZIP 1,41mo o ! SUBCONTRACTOR !`_C�� rj��,3 I W n PHONE SUBCONTRACTOR ADDRESS �CjITY/STATE/ZIP LICENSE �C-57 F1 C-61 EI D-09 F1 Other NUMBER -1 a ")-,1 dS EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i 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 New Well ❑ Replacement Well ❑ Well Alteration/Modification LI 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 Pum ❑ Pump Replacement ❑ Pump Repair J Raise Well Casing WELL CONSTRUCTION Drilling Method)66Mud Rotary ❑ Air Rotary Li Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 'L-q,.) ft Excavation �_ in diameter 11 Open Bottom ,yCGravel Pack/Gravel Size in diameter :1 Conductor Casing__in diameter / Conductor Casing Depth ft Well Casing Diameter C in Thickness/Gauge/ASTM Sched��— F1 Steel I5lastic FI Stainless Steel 11 Other Grout Seal Depth��ft ❑ Neat Cement(94 Ib bag/5-10 gal water) eSand Cement a,,-3 sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement MethodW-Rumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By 'Driller ❑ Pump Contractor I_I Other ❑ Concrete Pedestal ❑Dimensions:Width_L_f ft Length ft Thick X in ❑ Christy Box ❑ Stove Pipe PUMP I-Submersible❑ Turbine o Other HPC_ 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 �.;L �.'v,•I ORDINANCES, STATE LAWS, ANC Rt..... AND REI�UL.fiTIVN:J. I ALSO .,EK t iFY THAT I IVi i REQUIRED I i IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOU ADV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE DATE Wil . IV 10 i Q� U� D f` EP RTMENT U E NLY Application Accepted By Date �� Area Employee ID#� Grout Insper+ion By y- I Date ❑ SPECIAL Well Permit Pump Inspection By v Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMM TS NNS r PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Coder, Info By Cash Remitted Service Request# Z�m7 t 1 ?Z/1 r� 52. I ►5P6 1e5]- 1 -' EHD 43-06 8/01/16 WELL/PUMP PERMIT