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2- 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 m D CROSS STREET APN PARCEL SIZE LAND USE APPLICATION#Q a Z 1 m OWNER NAME PHotye ti :Ack)w OWNER ADDRESS CITY/STATE/ZIP 0 � CONTRACTOR PHONE (�/"1 •'�I J I ✓�� CONTRACTOR ADDRESS (/�/ CITY/STATE/ZIP S1 I dk� C 4192-15 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 2 q LICENSE [IC-57 ❑ C-61 I] D-09 11 Other NUMBER vrd((W EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Ll Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well Ij Well Alteration/Modification CI Other ❑ Monitoring Well(s) #of wells LI Soil Boring(s) #of borings Ll Geotechnical #of borings ❑ Out-Of-Service Well I Out-Of-Service Well Renewal ❑ Cross-Connection Repair C] New Pump KPump Replacement Ll Pump Repair Ll Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary 11 Auger ❑ Cable Tool Ll Push Point ❑ Other Proposed Well Depth ft Excavation in diameter U Open Bottom [I Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched H Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft I] Neat Cement(94 lb bag/5-10 gal water) I i Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall 1-1 Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller LI Pump Contractor 11 Other I I Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box FI Stove Pipe PUMP )<Submersible❑ Turbine LI 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 COMPENSATI. N LAWS. MI UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-LEASE CALL (209) 90-76P7 SIGNED TITLE DATE 71 111"kb il O R p HIM lEnli 4t __ 1 11 -?1- a r r PA TMENT U E N Y Application Accepted By Date Area Employee ID# Grout Inspection By Date I I f I L7 v SPECIAL Well Permit Pump Inspection By Date I I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received (ZeQW Amount Permit/ Co s Info B Cash emitted Date Service Request# Invoice# Well ID# 7 v ''' 0 EHD 43-06 8101/16 WELL/PUMP PERMIT