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s � 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 i 1 Li��eh / °l _S 36 m JOB ADDRESS+1 Ln �10. t'i'1 S D'E' i p� CITY/ZIP m CROSS STREET Z1 APN ��5 1 �vb�&(ARCELD �A: 2 SIZE LAND USE APPLICATION# o r �/ m OWNER NAME r ��f�� ✓ In�� rf J I P�ONE 7 Z f V rC c, o S"t Z0� 7 CITY/STATE/ZIP OWNER ADDRESS '7^ /�� /� CONTRACTOR I ZTrA O''1 `/�^Y e I I V / l CfSQ,, PHONE �J CONTRACTOR ADDRESS JDZ Lh�h��/�l�l `�`�f CITY/STATE/ZIP �U�1/�/"'�/ �� SUBCONTRACTOR T PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE KC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER (��-1�U� EXPIRATION DATE G/3 111q DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) i Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial a Water Quality Monitoring XSoil 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/Modi iffication 11 Other 11 Monitoring Well(s) #of wells 45oil Boring(s) "YF #of borings geotechnical _#of borings 11 Out-Of-Service Well 11Out-Of-Service�Well`Renewal ❑ Cross-Connection Repair ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 2.S `_3y ft Excavation A in diameter ❑ Open Bottom LI 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 9_.S_'?2y ft Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped )<Free Fall ❑ Other C1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor n Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine CI 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. MINIMUM 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)7953-/7697 SIGNED TITLE L° /oh;S/ DATE r ✓ q Q PAC q G E ARTMENT SE ONLY Application Accepted By Date V �" Area 1 Employee ID# + Grout Inspection B Date °{ ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received --Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Request# TZ 15 ��(oS�S 4 EHD 43-06 8/01/16 WELL/PUMP PERMIT