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i WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(29,9) 53-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS n1p, too CITY/ZIP' ^I m 2 /} ,�] D CROSS STREET APN / ✓ • XO� PARCEL SIZE 1• 2 LAND USE APPLICATION# o �Y M 2 M OWNER NAME ONE I OWNER ADDRESS 7 \ CITY/STATE/ZIP CONTRACTOR / t'VPHONE_7�1y CONTRACTOR ADDRESS `S. CITY/STATE/ZIP�I SUBCONTRACTOR PHONE 14 SUBCONTRACT R ADDRESS CI YlSTATE/ZIP LICENSE C-57 1-1 C-61 1 D-09 Li Other NUMBER 41ffN1EXPIRATION DATE DOMESTIC WELL STPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I I 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 J Replacement Well ❑ Well Alteration/Modification F1 Other F1Monitoring Well(s) #of wells El Soil Boring #of borings oringss) 11 Geotechnical ❑ Out-Of-Servic Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repairt- �� d ❑ New Pump Pump Replacement 7 Pump Repair II Raise Well Casing _V WELL CONSTRUCTION JA Drilling Method ❑ Mud Rotary [I Air Rotary a Auger f_I Cable Tool I1 Push Point ❑ Other rM Proposed Well Depth ft Excavation in diameter u Open Bottom 1 I Gravel Pack/GravelI ✓ In eter Ll Conductor Casing in diameter / Conductor Casing Depth ft /1 V/..II�R COUNT Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel LI Plastic ❑ Stainless Steel ❑ Otfi�PA TAC Grout Seal Depth ft r1 Neat Cement(94 lb bag/5-10 gal water) LI Sand Cement sack mix/� ITwater IJ Bentonite(20%solids) 11 Other Grout Placement Method I I Pumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By n Driller ❑ Pump Contractor I Other ❑ Concrete Pedestal nDimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible(( 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. IM IM 4 11?RD C NOTICE REQUIRED FO NSP TIONS - PLEASE CALL (209) 953-76 7 SIGNED / TITLE DATE q-1 All 4DUARTMENT U :iE ONLYq, Application Accepted By ( c— Date 1//� ( Area f Employee ID#. Grout Inspection B �� c �I \ Date Ll SPECIAL Well Permit Pump Inspection ByVY1�IVN \'y��( '�t�1�,0 Date OVA IJ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS '�l�±,'c Cs10 A-0,1 Qi�e� P,�,Ze Ir�i�' �- S .✓S 'u Skwer CIWWRr'14�i P Acf P Y All 4A 0 - — PE SC Received hec Amount Date Permit/ Invoice# Well ID# Codes Info ash Remitted Service Request# F42- EHD 43-06 8/01/16 WELL/PUMP PERMIT