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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 09 953-7697 FOR INSPECTIONS 4EXPIRES 1 YEAR FROM DATE ISSUED 1 � JOB ADDRESS r CITY/ZIP m �j D CROSS STREET APN O1/y,14kO r t.'] PARCEL SIZE!LAND USE APPLICATION# A Cn OWNER NAME PHHO`NEEy/ �[/��I OWNER ADDRESS © GLIN- CONTRACTOR CITY/STATE/ZIP �Gl� 4�/ �� C PH NE J 4&-&2�D CONTRACTOR ADDRESS ) oadCITY/STATE/ZIP �,O,a SUBCONTRACTOR PHONE SUBCONTRACTO ADDRESS TY/STATE/ZIP i LICENSE C-57 11 C-61 Ll D-09 1 Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) 1' Dibromochloropropane (4392) 1 1 Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 1-1 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 [I New Well Ll Replacement Well IJ Well Alteration/Modification 11 Other MEN 9 ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 11 Geotechnical R E 0 Ff ko; 177 ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair JAN A A9 5 C] New Pum Pum Replacement F] Pump Repair 11 Raise Well Casing WELL CONSTRUCTION SAN JOAQUIN COUNTY Drilling Method ❑ Mud Rotary ❑ Air Rotary r I Auger ❑ Cable Tool ❑ Push Point ❑ Other ENVIRnNA9€ ";;t Proposed Well Depth ft Excavation in diameter f_1 Open Bottom LI Gravel Pack/Grav H D=' in diameter Li Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic u Stainless Steel 0 Other Grout Seal Depth ft L_I Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water F1 Bentonite(20%solids) 1.1 Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other D Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller U Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP )(Submersible F1 Turbine f1 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. I I UM NCE N TICE REQUIRED FQJR INSP CTIONS - PLEASE CALL (209) 953-7697 SIGNED MIAL TITLE DATE DEARTMENT USE Application Accepted y Date �, NLy Area Employee ID#_(60/4gjZ� Grout Inspection By 1 Date(� �1 LiS ECTAL Well Permit V Pump Inspection By `� ��d v� Date l, ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received h Amount Date Permit/ Invoice# Well ID# Co es Info By Gash Remitted Service Request# 7-5-720 w-zZ P zZ EHD 43-06 8/01/16 WELL/PUMP PERMIT