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3 WELL/PUMP PERMIT 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�j/cA 0n t G) i J d L// M M p /� D CROSS STREET 1 APN 10:1 �� PARCEL SIZE 0•�q(YAND USE APPLICATION# M OWNER NAME Zr" U)�� PHONE �? OWNER ADDRESS2-14 r, os CITY/STATE/ZIP s �d i C� J O 52Z- C CONTRACTOR rL f� �/�P�HO�NE CJ Q �'�J CONTRACTOR ADDRESS 1 ` �f CITY/STATE/ZIP /�LCJ�4Ctf6/ � L57J SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / LICENSE X57 I C-61 I I D-09 i' Other NUMBER EXPIRATION DATE G / DOMESTIC WELL SAMPLING: Gene al Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private rrigation/Agricultural ❑ Industrial Fi Water Quality Monitoring I I Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK �<New Well I 1 Replacement Well ❑ Well Alteration/Modification 11 Other 11 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical #of borings I Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair I I New Pump Cl Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling MethodxMud Rotary ❑ Air Rotary I I Auger I I iable Tool LI Push Point I I Other Proposed Well Depth Svo ft Excavation � in diameter LI Open Bottom YGravel Pack/Gravel Size in diameter I I Conductor asing in diameter / Conductor Casing Depth ft Well Casing Diameter)I in Thickness/Gauge/ASTM Sched 10•7-S405teel r I Plastic I I Stainless Steel rOther Grout Seal Depth 50 IJ Neat Cement(94 Ib bay/5-10 gal water) Sand Cement sack mix/7 gal water I i Benton tte(20%solids) 11 Other Grout Placement Method Lumped ❑ Free Fall i Other I I Retardant/Accelerator(name) PEDESTAL Installed By I i Driller I I Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in I i Christy Box J Stove Pipe PUMP ❑ Submersible!i Turbine IOther 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. MINIMU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)) 953-76977 SIGNED ..�� TITLE L/^I1k ! DATE (—Al— tk Olds �ZA DEPA MENT USE ONLY Application Accepted By Date Area Employee ID#��" Grout Inspection By w Date t��1S 1L — D SPE dIAL Well Permit Pump Inspection By Date D WAIVER Received Soil Boring Inspection By Date Constructed—Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes l9fo ash Remitted Service Re ueSt# EHD 43-06 8/01/16 WELL/PUMP PERMIT