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WELL/PUMP PERMIT 1 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 y/� ,r/ ( 9 s� U V JOB ADDRESS LI ` �� " / n �� CITY/ZIP LV m 1 f D CROSS STREET IA-&k,.�� AJP�N O 6 S2 3-O D � PARCEL SIZE � sS LAND USE APPLICATION# A 12 m OWNER NAME Poklt'vZ71 �✓Al.♦��if� `� SL/1 l/I e— /+'/ PHONE OWNER ADDRESS S C4 W 1 CITY/STATE/ZIP CONTRACTOR PHONE 3 Z 7^3 I ZO CONTRACTOR ADDRESS /g�J� �`� V CITYISTATE/ZIP I L �J�LY� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE AWC-57 U C-61 ❑ D-09 r1 Other NUMBER -6Lf-O jtZ� EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE [JCDomestic/Private II 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 LI New Well ❑ Replacement Well I I Well Alteration/Modification Li Other F1 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 F1 New Pump 11 Pump Replacement Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method Ll Mud Rotary ❑ Air Rotary ❑ Auger 1-1 Cable Tool 11 Push Point U Other_ Proposed Well Depth_ ft Excavation in diameter I1 Open Bottom Gravel Pack/Gravel Size in diameter LI Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter IL in Thickness/Gauge/ASTM Sched AfSteel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft L Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water I Bentonite(20%solids) I 1 Other Grout Placement Method ❑ Pumped f 1 Free Fall U Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Ll Pump Contractor ❑ Other ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in ❑ Christy Box II Stove Pipe PUMP A'Gubmersible❑ Turbine i Other HP- 5 Pump Set /_JFO ft Standing Water Level Z37 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. MI I!rHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED TITLE ///4J'4% DATE 1 Z -1f-12 j/ Ic F-4 O0- A( T DEPARTMENT USE ONLY Application Accepted By Data - ' 1 Area I 6101 Employee ID# D Grout Inspection By Date IJ SPECIAL Well Permit Pump Inspection By Date 0 D' 2-O4 D WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 43 77 37 70 EHD 43-06 8/01/16 WELL/PUMP PERMIT