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WELL/PUMP PERMIT SAN 13-r�Q_UIN 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 1 AAa►14yno) '?03(, m JOB ADDRESS � � r�>nG� H1 - CITY/ZIP CROSS STREET �dG G 1 V�� A P N Z0 1240-1 PARCEL SIZE .0P LAND USE APPLICATION# OWNER NAME eA1-16S MU V t4 r C1 PHON� 51 o)�Sa- g3yo�L OWNERADDRESS Y ✓ l _ CITY/STATE/ZIP /�/�/ Cr,4YGa ) ` / :5334 CONTRACTOR tj 1,K �/�PHONE ./�/�[U�r 2 �] CONTRACTOR ADDRESS 119 A) � PA____ -___ _ CITY/STATE/ZIP /�IO��S�bl CC1 L �✓� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS _ _ CITY/STATE/ZIP LICENSE G-57 11 C-61 f 1 D-09 11 Other NUMBER S7 EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibrornochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private I 1 Irrigation/Agricultural I Industrial I I Water Quality Monitoring I I Soil Sampling/Characterization i Public Water System PA PAg-. If different from Owner: Water System Name Contact Name or Phone Numb TYPE OF WORK I I New Well Replacement Well U Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical ° ! of f r4ng�, ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 7 Cross-Connection Repair 90 ❑ New Pump F1 Pump Replacement ❑ Pump Repair Raise Well Casing SAP!JOAQUIN Cot WELL CONSTRUCTION HEALTH NMCfVTAL D�PA�rP��r�T Drilling Method<Mud Rotary _I Air Rotary I I Auger [_I Cable Tool ❑ Push Point Other Proposed Well Depth1-00 ft Excavation - jo 2– - in diameter f I Open Bottom Gravel Pack/Gravel Size in diameter I I Conduct r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 2C0 I 1 Steel Plastic 11 Stainless Steel I I Other Grout Seal Depth 1670 ft I I Neat Cement(94 lb bag15-10 gal water) I I Sand Cement sack mix/7 gal water /Xentonite 20%solids) ❑ Other Grout Placement Method I Limped ❑ Free Fall I I Other I I Retardant/Accelerator(name) PEDESTAL Installed By CI Driller Nflump Contractor I I Other 11 Concrete Pedestal UDi nsions:Width ft Length ft Thick in ❑ Christy Box I Stove Pipe PUMP ❑ Submersible',1 Turbine F1 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. MIN=HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-77697 SIGNED / TITLE Ori I bl- - DATE t C 11 A A 4 ki E P R T M E N T U S E O N L Y Application Accepted By Date Area Employee ID#� Grout Inspection By jwk Date Z ,1Z I 1 SPECIAL Well Permit Pump Inspection By Date I I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Che Amount Permit/odes Info B ash a tted Date Service Re uest# Invoice# Well ID# 0 7i EHD 43-06 8101/16 WELL/PUMP PERMIT