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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 J :�WW S' CITY/ZIP;9?J'Q<_`' C/t �/ m CROSS STREET /C^ 7 L APN, Ll(/U O (/O _�3 PARCEL SIZELAND USE APPLICATION# OWNER NAME 64/Z y A _ nPHONEe�&I OWNER ADDRESS _-;S�0 D0 �/�/77�f�� CITY/STATE/ZIP 'L CONTRACTOR Z I/-r `;4—i / G �j/`,�Jn I/y L^ P / �� PHONE C J �j Qcl l?7y CONTRACTOR ADDRESS /31 CI ( //2 PH IW177 le D r CITY/STATE/ZIP /` j4 c It/ �r SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CI (T 'Y/STATE/ZIP LICENSE KC-57 11C-61 L1 D-09 Cl Other NUMBER4je_o! SO EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE *X Domestic/Private ❑ 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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U Geotechnical # ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal U Cross-Connection Repair ew Pump ❑ Pump Replacement ❑ Pump Repair U Raise Well Casingu WELL CONSTRUC ION &W J 18 Drilling Method Ll Mud Rotary Li Air Rotary ❑ Auger Ll Cable Tool U Push Point U Other ,,_'em/1gQU/y,.. M Proposed Well Depth ft Excavation in diameter i 1 Open Bottom ❑ Gravel Pack/Gravel Size— P CT '&Mi '*P( [I Conductor Casing in diameter / Conductor Casing Depth ft �4RTMFNT Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel U Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) U Other Grout Placement Method ❑ Pumped U Free Fall U Other H Retardant/Accelerator(name) PEDESTAL Installed By U Driller IXPump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP N(Submersible❑ Turbine il Other FIP '12 Pump Set ft Standing Water Levelft 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. 48yHOUR AD NC NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-^/7697 SIGNED`/�"'�` 4y:%�/G TITLE �• DATE v 7 r J D PARTMENT USE ONLY Application Accepted By Date 2 Area Employee ID#AWW Grout Inspection By Date ❑ PECIAL Well Permit Pump Inspection By Date 103 11 aL 1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ec Amount Permit/ Codes Info Cash emitted Date Service Request# Invoice# Well ID# p q EHD 43-06 8101/16 WELL/PUMP PERMIT