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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 1311 S Cas+l-c. CITY/ZIP CC a.M44 • Cti M M CROSS STREET lJ 0 APN `�� /��_�� PARCEL SIZE rF9 W LAND USE AP`PL`ICATION# A OWNER NAME S�eLJP k.7�1 OLJA� {y�,1 I I 1 b��/'A �J J �'�.� I A L �/�PHONEdq��G vi OWNER ADDRESS 6S G�6k�40►'� /A CITY/STATE/ZIP /�fi�tq' era , � (S 33 6 CONTRACTOR Mad Gs ►✓• ` 'Tit' PHONE l_.522-/` Z6 CONTRACTOR ADDRESS I t Ft lkl VC_r J CITY/STATE/ZIP / ! e�to i Q L �35-7 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 1 1 C-61 I I D-09 I I Other NUMBER EXPIRATION DATE DOMESTIC WE SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private I I Irrigation/Agricultural I_' Industrial ❑ Water Quality Monitoring Li Soil Sampling/Characterization F] Public Water System If different from Owner, Water System Name Contact Name or Phone Number TYPE OF WORK )<New Well I I Replacement Well ❑ Well Alteration/Modification 11 Other Cl Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair F1 New Pump I I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method XMud Rotary f I Air Rotary I I Auger I1 Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 3W Excavation 1 2 in diameter CI Open Bottom X51 Gravel Pack/Gravel Size in diameter 11 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 2L Th ckness/Gauge/ASTM Schede I Steel Plastic I I Stainless Steel I I Other Grout Seal Depth TC �� lJ Neat Cement(94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water 'Bentonite(20%solids) ❑ Other Grout Placement Metho umped 71Free Fall r I Other i Retardant/Accelerator(name) PEDESTAL Installed By f I Driller '-Pump Contractor C1 Other Concrete Pedestal 'Dimensions Width ft Length ft Thick in Christy Box i I Stove Pipe PUMP Submersible❑ Turbine i I 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. MIM_U.�M.48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)//9``53-7697 SIGNED y .1� TITLE,rd) l/C �� r. DATE I 'G 4 J � 1 ! 1 _4 new lyt JA I' 4 I O �2), F M E/P�ARTMEN T U/SE (ONLY l / Application Accepted By �' t Date ''!t 'J /� Area S / C/ C� Employee ID# Grout Inspection By K_M AAj Date ` (� Ir ❑ SPECIAL Well Permit Pump Inspection By �- Date ❑ WAIVER Received Soil Boring lq pection By ( Date Constructed Well Depth ft COMMENTS 712 � M, t✓l IloAj�: C� '+ jt � S �t�j1�tII l:i� // 3 �i { f �� ',3(i /✓) C PE SC Received heck Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted I I Service R est# 4St 1k V �y� `�� O N EHD43-06 8/01/16 WELL/PUMP PERMIT