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WELL/PUMP PERMIT P/I 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 ✓ CITY/ZIP Lid) q,5124-0 m 7 �j D CROSS STREET APf�f] �/� y`Q PARCEL SIZE D- / LAND USE APPLICATION#/� �7 OWNER NAME Y / N PHONE 620 6) 61 Q 1 ^526 L. m? OWNER ADDRESS Cora,ttd CITY/STATE/ZIP Lad 1 i CA CONTRACTOR nof �J GPHONE 1— CONTRACTOR ADDRESS ` C CITY/STATE/ZIP v ✓�I SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: 'General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) , I Arsenic(4393) INTENDED USE K Domestic/Private ❑ Irrigation/Agricultural LI 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 CI 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 CI New Pum Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method FI Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter 1-I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) I-1 Sand Cement sack mix/7 gal water I_] Bentonite(20%solids) ❑ Other Grout Placement Method I I Pumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal FIDimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP )(Submersible[] Turbine ❑ Other HP (' L Pump Setft 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. M M HOU DVANCE NOTICE REQUIRED F INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNE TITL DATE71 O WCA X 1 1 .A, D E ARTMENT U S E O N L Y Application Accepted By Date Area Employee ID# U - 11 — -411al Grout Inspection By tw Date ❑ PECIAL Well Permit Pump Inspection ByAil � Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS DAVM ENT RECEIVED PE SC Received eck Amount Date Permit/ Invoice# e Codes Info By Cash Remitted Service Re uest# �a SAN OAQUIN COUNTY EHD 43-06 8/01/16 WELL/PUMP PERMIT