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i w 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 1-7L16 �� 9 i.?Ute- m JOB ADDRESS CITY/ZIP � � m s CROSS STREET XJ�Jyqalm AP PARCEL SIZE td a"fND USE APPLICATION# OWNER NAME R`) 'D tT �N�tO/W�//� •PHONE — y OWNER ADDRESS 1-7-746 (Joh l Shyp lVJ \ CITY/STATE/ZIP r CONTRACTOR A l I,.&)4- nfP� KJe-N W`L l/ Y/ PHONE 17-a1 70 45;9�_ CONTRACTOR ADDRESS 509 nAkMigour C&CAO CITY/STATE/ZIP ZiI UeITzre_ CA -S11 SUBCONTRACTOR a {� /PHONE SUBCONTRACTOR ADDRESS ^1�� CITY/ST�g ATEIZ-I-P7 LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER /f ! / EXPIRATION DATE /'31 I DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) i i Dibromochloropropane(4392) L: Arsenic(4393) INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System It different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK `<New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 11 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method,`Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth-M _ft Excavation � in diameter 11 Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 5 in Thickness/Gauge/ASTM Sched&Dk&�j ❑ Steel blastic ❑ Stainless Steel ❑ Other Grout Seal Depth 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 ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ump 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. NIMUM 48 HOU NC j�IOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95 7697 SIGNED G� TITLE_��k DATE 0 J L � �1RTMENT USE ONLY ENVIRE�q�N-L ' Application Accepted By Date Area dM� EeTI D# Grout Inspection By Date J PECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc ReceivedChec Amount Permit/ Codes Info B ash emitted Date Service Request# Invoice# Well ID# -0 1 EHD 43-06 8/01/16 WELL/PUMP PERMIT