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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED IJOB ADDRESS l7� W V rH n �1�1 ►�QG�� CITY/ZIP rAif 7/ MOY m ' D CROSS STREET � APN Q � PARCEL SIZE ND USE APPLICATION# A rn OWNER NAMEPHONEA"—V &f& / L(/ y OWNER ADDRESS I �S�IS'V CITY/STATE/ZIP CONTRACTOR PHONE 7 l q —6 ✓ - 502S LCONTRACTOR ADDRESS SLI .8-M d n S CITY/STATE/ZIPbrA, AP,� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / LICENSE & C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER U C EXPIRATION DATE /3 0 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring [ oil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well 11 Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings V,,deotechnical / 3 of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal U Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION / Drilling Method 11Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool Vl:'ush Point ❑ Other Proposed Well Depth 10-50 ft Excavation '2— in diameter ❑ Open Bottom U Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel E Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft 1-1 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) CI 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 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 WORKERS COMPENSATION LAWS. MINIMU?8 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-76/97 SIGNED TITLE e DATE D _ PA T M E N T USE ONLY Application Accepted By _ Date Area Employee ID#4� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By �1/ l Date LI WAIVER Received Soil Boring Inspection By ��^^'/�N�`� Date 4 /� Constructed Well Depth ft COMMENTS PAYME °r PE SC Received Check Amount Date PermiU Invoice EIVEDD# Codes Info B Cash emitted Service Request# JOA UIN COUNTY FiNVIRONMENTAHEALTH F EHD 43-06 8/01/16 WELL/PUMP PERMIT