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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 VON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS /f7 / r/ �V y ��!/ CITY/ZIP ! 0 C D� m CROSS STREET / APN y PARCEL SIZE LAND USE APPLICATION#Z. f /y,/' OWNER NAMcn E C V l 1.L PHONE �t .�C ly c? OWNER ADDRESS CITY/STATE/ZIP �/ L, CONTRACTOR PHONE `7Z.. 2 2, CONTRACTOR ADDRESS t� CITY/STATE/ZIW'!./'��4/l/ I r -, kC, , SUBCONTRACTOR I 6+p ,— PHONE �2 SUBCONTRACTOR ADDRESS CITY/STATE/ZIP _ L LICENSE XC-57 E]C 61 [ID 09 El Other NUMBER `l J EXPIRATION DATE 3& DOMESTIC WELL SAMPLING:[General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE omestic/Private ❑Irrigation/Agricultural []industrial E]Water Quality Monitoring El Soil Sampling/Characterization ❑Public Water System If different from Owner: Water bystem Name Contact Name or Fhone Number TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification El Other [I Monitoring Well(s) #of wells [-]Soil Boring #of borings s) ❑Geotechnical #of borings F1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair ArNew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling MethoOFrMud Rotary ❑Ai"ti ry ❑Auger ❑Cable Tool E]Push Point ❑ Other Proposed Well Depth3,50 < if�Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter F-1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter Ic— in Thickness/Gauge/ASTM Sched-2-00 [:]Steel ,Plastic ❑Stain) ss Steel ❑Other Grout Seal De ft El Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water ❑ /o solids) ❑Other Grout Placement Metho Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contractor ❑ Other -- El Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box [-]Stove Pipe PUMP lyeubmersible❑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 COMPENSATION LAWS. MINI M 4 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE DATE DATE st 6y 71— T D Aquiriff lT EN A 1 Y CL E T TT; E ARTMENT U E NLY Application Accepted By Date Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date 5, 1 ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth 3' (J ft COMMENTS j h IA 611-- V~IMIAI la"ZA .✓ c. PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# Codes Ifo j3yn cash Remitted Service Request# ,3 ,i�FLY---' _�'r.• EHD 43-06 8/01116 WELL/PUMP PERMIT