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WELL/PUMP PERMIT hP f SAN J0A2UIN CGUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT C L 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED `JCB ADDRESS ?V V 3� ff CITY/ZIP J m �/� z D CROSS STREET APIN W PARCEL SIZE_1(/��'w LAND US PPLICATION# S OWNER NAME f� �!i � (APHO E l a �? OWNER ADDRESS ` I Z / L �U— CITY/STATE/ZIP CONTRACTOR PHONE r �(/y L) CONTRACTOR ADDRESS Lan , A i II CITY/STATE/ZIP SUBCONTRACTORAk V PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 -I C-61 D-09 fl Other NUMBER Abs V D EXPIRATIONDATE—E3L DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ! Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Dome stic/PrivateIrrigation/Agricultural 1_I Industrial 0 Water Quality Monitoring I I 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 L Well Alteration/Modification Cl Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings J Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal CI Cross-Connection Repair Fl New Pump 0 Pump Replacement 1"1 Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method *Mud Rota 1 i Air Rotary [i Auger [I Cable Tool 11 Push Point Li Other Proposed Well Depth__R. tq Excavation lb in diameter ❑ Open Bottom n Gravel Pack/Gravel Size in diameter ❑ Conductor Casing U in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel U Plastic ❑ Stainless Steel ❑ Other Grout Seal DepthID 1 _ft ❑ Neat Cement(94 lb bag/5-10 gal water) '�LSand Cement IU'✓ sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method F1 Pumped I_l Free Fall ❑ Other CI Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal I I Dimensions:Width ft Length ft Thick in I I Christy Box 11 Stove Pipe PUMP ❑ Submersible❑ Turbine 1_I Other HP-f:'jLj 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 WORK E S COMPENSATION LAWS. M IMUPA 24,WUP,ADVANi E NOTICE REQUIRED FOR INSP TIONS - PLEASE CALL (209 913- 6 tfA SIGNED I TITLE DATE IL 8 A T 0 U A C PA TMENT US-E ONLY Application Accepted By Date Area Employee ID# Grout Inspection By Date - J SPECIAL Well Permit Pump Inspection By 1a Date Ifi ❑ WAIVER Received Soil Boring Inspection By Date I11Constru-cted Well Depth � I� ft COMMENTS` I f �( %f7 I 11 )VT I M - _ V-/ /1 L,L&I PE SC Received C Amount Permit) .CLodes Info B Cash emitted Date Service Request# Invoice# Well ID# r EHD 43-06 8/01/16 WELL/PUMP PERMIT