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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED / Ln JOB ADDRESS CITY/ZIP ( ` m /� C D CROSS STREET AlN ,o PARCEL SIZE •' J LAND USE APPLICATION# A ar m OWNER NAME ! PHONE Sa 5 tl �,K r i � 1 �/) " OWNER ADDRESS CITY/STATE/ZIP ,,((�� ! 04-Cl j J /�� CONTRACTOR HONE SOS q3/ 32i- J CONTRACTOR ADDRESS CITY/STATE/ZIP LzahnlZ4 �iC/!J SUBCONTRACTOR PHONE SUBCONTRAC OR ADDRESS ITY/STATE/ZIP LICENSE C-57 l C-61 11 D-09 ❑ Other NUMBE A04) EXPIRATION DATE —3idl DOMESTIC WELLS MPLING: i General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) i Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 1-1 Soil Sampling/Characterization ❑ ublic Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well Ll Well Alteration/Modification ❑ Other or Li Monitoring Well(s) #of wells [I Soil Boring #of borings s) LI Geotechnical �� ings 11Out-Of-Service II L1 Out-Of-Service Well Renewal U Cross-Connection Repair , F] New Pum Pump Replacement f 1 Pump Repair 11 Raise Well Casing WELL CONSTRUCTION J4 A� Drilling Method ❑ Mud Rotary LI Air Rotary ❑ I11Auger 1 Cable Tool I I Push Point Other ''11I1�lr 2 uly Proposed Well Depth ft Excavation in diameter 11 Open Bottom ❑ Gravel Pack/Gravel ' JOA m ameter Ll Conductor Casing in diameter / Conductor Casing Depth ft H��Ty�UN7Y Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Othtpq A( Grout Seal Depth ft I I Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixt 1al water ❑ Bentonite(20%solids) I I Other Grout Placement Method ❑ Pumped LI Free Fall 11 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 11 Pump Contractor 11 Other Concrete Pedestal IDimensions:Width ft Length ft Thick in ❑ Christy Box 11 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 WORKERS COMPENSATION LAWS. MI IMUM D �E�NC E REQUIRED FO INSI NS -PLEASE CALL (209) 53-7697 r� SIGNED '(N f TITLE DATE if EP RTMENT U E ON Y Application Accepted By Date Area Employee ID# Grout Inspection By nn��,, Date LlPECIAL Well Permit Pump Inspection By 't�CT`�(��N�"mj � Date Z l WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received he Amount Permit/ Codes Info B ash emitted Date Service Request#10 Invoice# Well ID# EHD 43-06 8/01/16 WELL/PUMP PERMIT