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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 n,C'ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS t \1\150 E �VM "ne CITY/ZIP Lod i 95,7_41. CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADDF SUBCONTRACTOR SUBCONTRAC R� LICENSE kc-5 AD0' I �/ PARCEL SIZE ir-a. / PLASct*ctA► A -4-G 7 ❑ C-61 ❑ D-09 ❑ Other NUMBER`Tr)V Q1 LA' DOMESTICNWELLSA PIING: i General Mineral/Coliform Bacteria (4391) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Public Water System If different from Owner: Water System Name LAND USE�AjPPP/LICCAATION # PHONE % 2. — 52-1PHONE �o / PHONE EXPIRATION DATE A - Dibromochloropropane (4392)1 Arsenic (4393) ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization 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 ❑ Geotechnical # of borings ❑ Out -Of -Service ell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pum Pum Re lacement ❑ Pum Re air ❑ Raise Well CasinWELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft I Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) IJ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name)Installed By ❑ Driller ❑ Pump Contractor ❑ Other❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe IPUMP W Submersible❑ Turbine I I 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 WORKEbt� WMPENSATION LAWS. SIGNED - PLEASE CALL (2( DATE ►1 .11 � A'� .D ' =F%0 11101r�'t Areatdao Employee ID#h d❑ PECIAL Well Permit�,❑ WAIVER Received Constructed Well Depth ft EHD 43-06 8/01/16 WELL /PUMP PERMIT T mo mm DE ARTMENT USE NLY Application Accepted ByA DateGrout Inspection By DateDPump Inspection By P�aJ fxll?t19� Date /IL-Q)!%Soil Boring Inspection By Date COMMENTS ►1 .11 � A'� .D ' =F%0 11101r�'t Areatdao Employee ID#h d❑ PECIAL Well Permit�,❑ WAIVER Received Constructed Well Depth ft EHD 43-06 8/01/16 WELL /PUMP PERMIT T mo mm