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WELUPUMP PERMIT 13AN JOAQUIN CCUNTY 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 JOB ADDRESS 070- ye CITY/ZIP !/ m f D Q/ CROSS STREET APN W PARCEL SIZ43 LAND Uaj;,APPLICATION# o r1�aP�1 OWNER NAME f f� AI ' PHO E t� c? OWNER ADDRESS 1 7i L�aj/ �w CITY/STATE/ZIP b CONTRACTORkrh' PHONE q 10 CONTRACTOR ADDRESS lan I v A V MW CITY/STATE/ZIP Q SUBCONTRACTOR'jjf\�l PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER - CJ EXPIRATION DATE. DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria(4391) CI Dibromochloropropane(4392)u Arsenic(4393) INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ,Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation Ib in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing_ in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal wafer) '�LSand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ 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 WORKHSCOMPEjNSATION LAWS. U �24JURADVAKE NOTICE REQUIRED FOINSP TIONS -PLEASE CALL (209 9 -1 6 ,7 SIGNED TITLE DATE ' r 8 T.11 O U C PA T M E N T US ONLY Application Accepted By Date Area Emplovee ID# Grout Inspection By / Date ❑ SPECIAL Well Permit Pump Inspection By 6 Date a ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth i�.'L ft COMMENTS Y )� (" t 1/ 00 I C PE ` SC Received C Amount Permit/ odes Ifo By_ Cash emitted Date Service Request# Invoice# Well ID# sY eqsz :ZEE r EHD 43-06 8/01/16 WELL/PUMP PERMIT