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'Ir1141ak S loan I1'5- 6 WELL/PUMP PERMIT USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT % CALL 1209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 00 JOB ADDRESS •� n ) CITY/ZIP Q �v O m ,+�I/� 1 •� m CROSS STREET /r/� APN V b"1 1�y E 3'j '� v PARCEL SIZ AN USE APPLICATION# v t m OWNER NAME /" L/(�/Ii� n L{ PHONE " OWNER ADDRESSI r✓yy-e/ � CITY/STATE/ZIP ?j CONTRACTOR ' / A P-- ,rPHONE CONTRACTOR ADDRESS +��1 CITY/STATE/ZIP "'� '�•J/"�� SUBCONTRACTOR a0a Z16)a!t 944-,, PHONE7Vj �✓7�/ SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE $[C-57 ❑C-61 ❑D-09 ElIT Other NUMBER 2-7-7 3;05 EXPIRATION DATE �t7 1-7 - 6—__�o DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring E]Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 4ilew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other [I Monitoring Well(s) #of wells E]Soil Boring #of borings s) E]Geotechnical #of borings E]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ew Pump ❑Pump Replacement ❑Pump Repair [:)Raise Well Casing WELL CONSTRU TION Drilling Method<Mud Rotary ❑Air Rotary El Auger ,❑Cable Tool E]Push Point E] Other Proposed Well Depth �V ft Excavation 1Lf in diameter E]Open Bottom *ravel Pack/Gravel Size in diameter ❑Conductt Casing in diameter / Conductor Casing Depth ft Well Casing Diameter O in Thickness/Gauge/ASTM Sched_L—_y'3 ❑Steel MPIastic ❑Stain"le�ss Steel ❑Other Grout Seal Depth 3 C ft ❑Neat Cement(94 lb bag/5-10 gal water) 'Sand Cement Cy;�� sack mix17 gal water [:]Benton ite(20%solids) ❑Other Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By -<Driller [:]Pump Contractor ❑ Other ❑Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP <SubmersibleOTurbine ❑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. MI I UM 4H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED K1- TITLE �Cy.�-� DATE INl a � a 5 N R " EI i EP RTMENT US ONLY n r, Application Accepted Date Area "l Employee ID# %= (C Grout Inspection*Byt4_� r Date ❑ SPECIAL Well Permit Pump Inspection JWL4eTDate ❑ WAIVER Received Soil Boring spection By Date Constructed Well Depth COMMENTS O G L PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# Codes Ifo B Remitted Service Request# lZ - V DO 14 q EHD 43-06 8/01/16 WELL/PUMP PERMIT