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A/�J` 7j ;, it WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE �PERMIT q4V209)95,3--7/697 FO /INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED IOBADDRESS (� /J �1 Ci ��.s - �( �Nr4. CITY/ZIP m GROSS STREET W1 0 L 1 f/i L� y� (�j�^" 1� 3�f� D APN �/ �. PARCEL SIZE LA D USE APPLICATION# o �+ m •OWNER NAME bL 1 �/f��/(V.�` 1�.0 L C_ C—�� HONE �/ OWNER ADDRESS :3x /! V✓Y�J �I 1/STATE/ZIP �o Cc, CONTRACTOR (/,!eGr�f.�� /•--,` Z ,+ JPHON�E} 5 �- CONTRACTOR ADDRESS 1V �f" l CITY/STATE/ZIP 44 60✓91ZI4gAd- SUBCONTRACTOR ; 7-4 G a0c5— R"r PHONE LJ " y I LJ SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ` l LICENSE C-57 [1 C-61 [11 D-09 El Other NUMB /ER is 73 91. EXPIRATION DATE DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) INTENDED USE ;;�"omestic/Private ❑Irrigation/Agricultural ❑Industrial [:]Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name on acName or Phone Number TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other [-]Monitoring Well(s) #of wells E]Soil Boring(s) #of borings ❑Geotechnical #of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal []Cross-Connection Repair ew Pump El Pump Replacement El Pump Repair E]Raise Well Casing WELL CONSTRUCTION Drilling Method,)�Wud Rotary El Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other Proposed Well Depth ft Excavation in diameter L1 Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conduct/or Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6 in Thickness/Gauge/ASTM Schec'*1-00 ❑Steel XPlastic E]Stainless Steel ❑Other Grout Seal Depth?_X ft ❑Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water F]Bentonite(20%solids) ❑Other Grout Placement Method []Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal dimensions:Width ft Length ft Thick - in ❑Christy Box ❑Stove Pipe PUMP Submersible❑Turbine ❑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. MINIMLJM 24 OOUR VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9953-7697 SIGNED . TITLE �� DATE v O �T[1771 11 F- c 8 H P TMENT U E NLY ANpiicafion Accepted By nate Arear'm Employee ID# — Grout Inspection By /� Date Z L SPE IAL Well Permit Pump Inspection By Date ok E] WAIVER Received Soil Boring Inspection B Date Cons1ructeddW�ell Depth ,�J�J ft , COMMENTS �� I �' L( _ Cl I61f- 0 o bi�fn PE SC Received Amount ate Permit/ Invoice# Well ID# Codes fo B ash Re itted Service Request# I� 1 EHD 43-06 8/01/16 WELL/PUMP PERMIT