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1' 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 `I c rn JOB ADDRESS F-. ``1 on G6 Y�� CITY/ZIP E SCO, c n 9T32 .O m CROSS STREET APN 1477 80-05 PARCEL SIZE3'1.5!f 9.3'f LAND USE APPLICATION#r E u to 1C P Nbbr�rnan PHONE59 PPI S - 904-7 C? OWNER NAME C, �J OWNERADDRESS �(oZ�J--1 F -�Onc-_5 CITY/STATE/ZIP E.SCo.\ "n'ir'R p CONTRACTOR � r\ PHONE 545 -n11,8 5 /_ CONTRACTOR ADDRESS tot �—QQ1 CITY/STATE/ZIP�1 �0d e 5� R c, � l J 3 S 10 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP C 2 LICENSE C-57 ❑ C-61 [1 D-09 ❑ Other NUMBER 2 91 j EXPIRATION DATE CJ_3 ZQ DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private Cl Irrigation/Agricultural ❑ Industrial LI Water Quality Monitoring ❑ Soil Sampling/Characterization LI Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ew Well Yeplacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well Li Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pum ❑ Pump Replacement CI Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point a Other Proposed Well Depth ft Excavation _4 in diameter I l Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter$ in Thickness/Gauge/ASTM Sched 5DIL ❑ Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth `0_ft f7 Neat Cement(94 lb bag/5-10 gal water) U Sand Cement sack mix/7 gal water Bentonite 20°/a solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor LI Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUI OR INSPECTIONS - PLEASE CALL (209) 953-76977 1 V �' DATE n 1 SIGNED TITLE ear 0 sq Py N U� T 7y T T DEPARTMENT USE NLYY io Application Accepted By LDate 7 f,> Area Aq Employee ID# Grout Inspection By Date z ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection ByDate Constructed Well De th ft COMMENTS ��tS ' r^ PE Sc Received Che Amount Date Permit/ Invoice# Well ID# Cod s, Info BYA4 Cash Remitted Service Request# n _401 I1'r8' 1�Z �F 19Who 3 EHD 43-06 8/01/16 WELL/PUMP PERMIT