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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 CALL,,I(209 953-7697 FOR INSPECTIONS EXPIRES/1 YEAR FROM DATE ISSUED LPv JOB ADDRESS v [ m Y v 7 1 S CITY/ZIP/`�G{ J`d a/ "1 /�W 1 m CROSS STREET+~1I APN '2 U / 2 +7 �' �� PARCEL SIZE /�� ll LAND USE ^�APPLICATION# �` OWNER NAME L�7� 'QL em e_rs%VI a l ��en Ll i C r I t A i ./ PHONE Z��S99/� Z�O<-./s OWNER ADDRESS ✓Vf� CITY/STATE/ZIP �� C, U r//''''C ✓1 9 J 3;t CONTRACTOR v rn -/—r 1 ' +/C) ,-) PHONE �/�S/� (!AL3!i—o q jj,I CONTRACTOR ADDRESS E CITY/STATE/ZIP/)l a/7AeeC1 '1)�i SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE//ZIP LICENSE ❑ C-57 P<7611i I D-09 I Other NUMBER yZ�9(,y EXPIRATION DATE k 31— 7«CO�/� DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) Arsenic(4393) INTENDED USE ie 6omestic/Private Ll Irrigation/Agricultural I 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 C New Well Ll Replacement Well ❑ Well Alteration/Modification I I Other bA F-, g� Monitoring Well ❑ g #of borings i g Well(s) #of wells Soil Boring(s) ! Geotechnical� Cie/ �! F1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair ie/Ve® ew Pum 1 Pump Replacement D Pump Repair Raise Well Casing WELL CONSTRUCTION 05 `0 Drilling Method i Mud Rotary 1_1 Air Rotary 11 Auger Cable Tool I I Push Point ❑ Other SAND C ,`�r, Proposed Well Depth ft Excavation in diameter !I Open Bottom 11 Gravel Pack/Gravel Si h V�� ffl�tgr Conductor Casing in diameter / Conductor Casing Depth ft n DEl'+4R„Tr/HENT Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel I I Plastic I Stainless Steel ❑ Other Grout Seal Depth ft I I Neat Cement(94 lb bag/5-10 gal water) I' Sand Cement sack mix/7 gal water Bentonite(20%solids) ;J Other Grout Placement Method 11 Pumped ❑ Free Fall I I Other I I Retardant/Accelerator(name) PEDESTAL Ins ed By ❑ Driller I ump Contractor I Other Concrete Pedestal ❑Dimensions:Width A ft Length ft Thick:ein n Christy Box a Stove Pipe PUMP ubmersible❑ Turbine Other HP 3 Pump Set ft Standing Water Level /l0 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 COMPENSATIO LAWS. MI 4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697Q SIGNED TITLE VIa� GV DATE All I i D A R T M ENT USE ONLY n Application Accepted By Date '-2- S' i C) Area C1 Employee ID# Grout Inspection By f� Date 1 ❑ SPECIAL Well Permit Pump Inspection By Date �. �1�� t.�;� ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info BV, s Remitted Service Request# Fla 5,"� 2-�j I� W t70 ZS EHD 43-06 8/01/16 WELL/PUMP PERMIT