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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 fC ��iJ m JOB ADDRESS � Lq+ CITY/ZIP m � n - n APN CROSS STREET � PARCEL SIZE `� LAND USE APPLICATION# OWNER NAME P PHONE /II✓ ^�U'55 m OWNER ADDRESS V CITY/STATE/ZIPMffjdn� ( a 'J� CONTRACTOR ` ONEG I. CONTRACTOR ADDRESSby CITY/STATE/ZIP f�'2C. � - SUBCONTRACTOR A PHONE SUBCONTRAC R ADDRESS C /STATE/ZIP / LICENSE C-57 C-61 Ll D-09 11Other NUMBER EXPIRATION DATE 'j/ DOMESTIC WELL SAMPLING: "i General Mineral/Coliform Bacteria(4391) ' Dibromochloropropane(4392) i Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I l Water Quality Monitoring Ll 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 # JAU �� ❑ Out-Of-Service II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair Ref%p-.. T I-1 New Pum K—Pump Replacement ❑ Pump Repair ❑ Raise Well Casing 1/ WELL CONSTRUCTION 10 28 Drilling Method ❑ Mud Rotary 11 Air Rotary ❑ Auger ❑ Cable Tool f 1 Push Point ❑ Other 2019 Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size / M TY ��er ❑ Conductor Casing in diameter / Conductor Casing Depth ft y EPgR L Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other ENT Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) L Other Grout Placement Method ❑ Pumped Ll Free Fall U. Other Ll Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller U Pump Contractor Ll Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible[] Turbine I1 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 C MPENSATION LAWS. N 2 U V CE/N�OTI REQUIRED FOR INSPEC IONS -PLEASE CALL (209) 53-7697 J SIGNED VLti� TITLE DATE r td I 77 P RTMENT U E ONLY Application Accepted By / Date / Area Employee ID# yyy Grout Inspection By ''\\ `� M n�� Date ❑ SPECIAL Well Permit Pump Inspection By N `[��U�C/C��Nf Date l I G l b�� ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info y Cash 1 emitte Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT