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WELL/PUMP PERMIT SAN J WQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 ON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED t C2 2� � JOB ADDRESS 1 l �'��G� G ��t_ fl CITY/ZIP �A� ��) ��/�/(/� m I t D PJ CROSS STREET SaG L' APN 20(o—120'1 W PARCEL SIZE .OfO LAND USE APPLICATION# J/ U) OWNER NAME C aTt V S Tyy a r PHONI S 1 0 )-7-50- 430 ��130 N OWNER ADDRESS ZP V ✓4 __ CITY/STATE/ZIP AR�Ga ) Ce, 1:5334 CONTRACTOR C �.tPA1 k k PHONE CONTRACTOR ADDRESS I Af � ___ CITY/STATE/ZIP /�/►/ }I O �S 1 Dy CQel -L 5 3 -7 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP LICENSE C-57 CI C-61 I D-09 I I Other NUMBER SJ EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (439 1) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE Domestic/Private I I Irrigation/Agricultural I_I Industrial I I Water Quality Monitoring I I Soil Sampling/Characterization ❑ Public Water System PAY_%Lir ®^� If different from Owner. Water System Name Contact Name or Phone Numb TYPE OF WORK INew Well Replacement Well Well Alteration/Modification ❑ Other }" I i Monitoring Well(s) #of wells '_1 Soil Boring(s) tlof borings Geotechnical ;`#of.bofings ta� I Out-Of-Service Well -i Out-Of-Service Well Renewal ❑ Cross-Connection Repair St New Pump I Pump Replacement n Pump Repair [I Raise Well Casin SAN JOAQU;fq WELL CONSTRUCTION 1i EA_I NMENTAL TH DrpARTNJFP4T Drilling Method<Mud Rotary ❑ Air Rotary I I Auger I' Cable Tool ❑ Push Point LI Other Proposed Well Depth1-00 ft Excavation - /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 2� I Steel Plastic I I Stainless Steel ❑ Other Grout Seal Depth /0 O ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water ,>'T3entonite 20%solids) ❑ Other Grout Placement Method 1 Limped n Free Fall Other Retardant/Accelerator(name) PEDESTAL Installed By ❑ Drillerump Contractor I I Other I Concrete Pedestal I IDi nsions:Width ft Length ft Thick in Christy Box -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. MIN 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE �✓7 /�C�- DATE Prnje ,. EP R T M E N T US.//E ONLY Application Accepted By Date v� Area /?qEmployee ID#� Grout Inspection By Date Z, 4?, ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Ins ection By Date Constructed Well Depth ft COMMENTS LQ —j,0jQL0 PE SC Received Che Amount Date Permit/ Invoice# Well ID# odes Info By ash a "tted Service Request# O Z II-I�,z WP0 0" II-IV�'Ii� W�0 oy-- EHD 43-06 8/01/16 WELL/PUMP PERMIT