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i r: 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 V'S-71 1 S Cas�1� CITY/ZIP / 1a�l�tca , [q m JOB ADDRESS _ m p Q �/� Q D CROSS STREET �ywl t**- " k APN l `-1` 1�_r"& PARCEL SIZE C7r �,/� ` Z rip 2�LAND USE(A�PlPL`ICATION#1 A OWNER NAME e(JP r O�II7 1 1��'/� �J J.' v.� tr I /1 L �/�PHONEE Vy� /+-_ `Vvii OWNER ADDRESS _16S Gr�-F•}-y►� � /��« CITY/STATE/ZIP M, I��a C, (S 331�, CONTRACTOR M�se11 1 ✓•-1lt , Z'At' PHONE 522- 142-5 CONTRACTOR ADDRESS I I VG�S ` CITY/STATE/ZIP N��`eif o , SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIPy�r LICENSE C-57 I C-61 Il D-09 Other NUMBER EXPIRATION DATE /�/ O_/ / DOMESTIC WE SAMPLING: \-General Mineral/Coliform Bacteria (439 1) Dibrofnochloropropane(4392) Arsenic(4393) INTENDED USE bomestic/Private h Irrigation/Agricultural 11 Industrial 11 Water Quality Monitoring ij Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK XNew Well I I Replacement Well I I Well Alteration/Modification I I Other i l Monitoring Well(s) #of wells i I Soil Boring(s) #of borings 1 11 Geotechnical #of borings I I Out-Of-Service Well i I Out-Of-Service Well Renewal ❑ Cross-Connection Repair I I New Pump i I Pump Replacement 1 I Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method XMud Rotary f1 Air Rotary Auger I I Cable Tool i Push Point fl Other oe Proposed Well Depth3W 1 ft Excavation 1 2 in diameter F! Open Bottom yGravel Pack/Gravel Size in diameter ! Conduct r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter i Th ckness/Gauge/ASTM Sched �0 i Steel Xplastic i Stainless Steel Other Grout Seal Depth ❑ Neat Cement(94 Ib bay/5-10 gal water) Sand Cement sack mix/7 gal water 'Bentonite(20%solids) ❑ Other Grout Placement Meth o umped ❑ Free Fall I I Other Retardant/Accelerator(name) PEDESTAL Installed By 1 I Driller 'XPump Contractor I Other ❑ Concrete Pedestal ❑DimensionsWidth ft Length ft Thick in 1 I Christy Box I I Stove Pipe PUMP fl 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. MI MUM48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED /TITLE IdGr• DATE J ! ) _4 l � 1 q( O C F M _411�EPARTM EN I- ]USE ON(�LY Date i 1)-1 / Area 3)C�� Em to ee ID# A Application Accepted By aa ( L Employee Grout Inspection By Q(t �T;e�� 1An., Date �r 00 ❑ SPECIAL Well Permit Pump Inspection By �— Date ❑ WAIVER Received Soil Boring lq pection By Date Constructed Well Depth ft COMMENTS "C ( "", (� o r h ULA �: i 1 � � 3 t � S Z✓�� t�t II 1 . l I � �i f f l'i'i PE Sc Received Tqeck#V Amount Permit/Cod1es Info _'__By.' C'ash Remitted Date Service R est# Invoice# Well ID# 3b ` oIS ► EHD 43-06 8/01/16 WELL/PUMP PERMIT