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k 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 D 2 CITY/ZIP T/'�r'y� f m �j 3- D—D D CROSS STREET /�/A"r/ � APN PARCEL SIZE��LAND USE APPLICATION# A L m OWNER NAME /I A / � PHHONNE� J OWNER ADDRESS �/�SL eA^FA CITY/STATE/ZIP5[�_1z CONTRACTOR /ll�/� i'//V(� /r �f^/C 7v/�^— PHONE CONTRACTOR ADDRESS �f �O _ CITY/STATE/ZIP S//� /(/ SUBCONTRACTOR Q F//c�� PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 57 U C-61 11 D-09 I I OtherNUMBER / EXPIRATION DATE / �l DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibroinochloropropane (4392) Arsenic(4393) INTENDED USE � omestic/Private ❑ Irrigation/Agricultural !1 Industrial I I Water Quality Monitoring [1 Soil Sampling/Charac 1�� /❑ Public Water System mf_ If different from Owner: Water System Name Contact Name or Phone Number / vEh TYPE OF WORK n New Well ^eplacement Well ❑ Well Alteration/Modification F I Other A4d V . ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I i Geotechnical ngPO18 ❑ Out-Of-Service Well ❑ OUt-Of-Service Well Renewal LI Cross-Connection Repair �oAQU/ ,WNew Pum -1 Pum Replacement FI Pump Repair n Raise Well CasingH E1 - Afy .O� Y UEFP WELL CONSTR CTION �1RTjIfENT Drilling Method )"Mud Rotary J Air Rotary [I Auger I i Cable Tool i I Push Point F1 Other Proposed Well/Depth 10 ft Excavation 1Z in diameter ; Open Bottom ravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter.-b- in Thickness/Gauge/ASTM Sched 7_410 1 I Steel lastic I i Stainless Steel ❑ Other Grout Seal Depth /Gp ft ❑ Neat Cement(94 Ib bay/5-10 gal water) �I 1 Sand Cement sack mix/7 gal water Xtentonite(20%solids) ❑ Other Grout Placement Method umped ❑ Free Fall ❑ Other I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller YPump Contract / ❑ Other Concrete Pedestal IJDi ensions:Widt ft Length=41&Z ft Thickin ❑ Christy Box ❑ Stove Pipe PUMP ubmersible❑ Turbine 1_I Other HP Pump Set_/Q0 ft Standing Water Level —R 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 O ANCE NOTICE REQUIRED FOR I SPEMC/T�I^ONS - PLEASE CALL (209) 953;,7697 SIGNED TITLE DATE Z r► f IF 14 19W EP RTMENT U F ONLY Application Accepted By \ Date Area Employee ID am Grout Inspection By J Dat , Ij SPECIAL Well Permit Pump Inspection By Date l ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTSRQ-7 PE SC Received heck Amount Date Permit/ Invoice# Well ID# C Info B ash Remitted Service Request# �1 V 5 7 5 10 3 L,3 2 V V EHD 4'--06 8/01/16 WELL/PUMP PERMIT