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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 EXTPIIRE/S�1 YEAR FROM DATE ISSUED LA ' JOB ADDRESS , Ave C v'Okot TMckl CITY/ZIP CROSS STREET k)4 V y D/1- y'r APN I4L 03 0G PARCEL SIZE LAND USE APPLICATION# A A n ` rm� OWNER NAME POA-r o F ST°G krO A.1 PHONE � J rp OWNERADDRESS ZZD/ W. GtJ/SNz,e��TI�/ S) ' CITY/STATE/ZIP' 704k7VA L- 'Z0,T CONTRACTOR V.0' u/ D/L77eL.Z-��JvG. PHONE ^ Q `j d/. A?" ?II ; T�O CONTRACTOR ADDRESS I/33 JS LAt" A10X57-57 JDn"Tt)-f CITY/STATE/ZIP 6 4a t r e-A -95-jrJ J SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CrTY/STATE/ZIIPP LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER 72 07d 7 EXPIRATION DATE d Z a Za DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)T Dibromochloropropane(4392)T Arsenic(4393) INTENDED USE j Domestic/Private ❑Irrigation/Agricultural L Industrial ❑Water Quality Monitoring 91.Soil Sampling/Characterization j Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 7 New Well ❑Replacement Well E-Well Alteration/Modification 7 Other I Monitoring Well(s) #of wells OL6oil Boring(s) #of borings pt6eotechnical #of borings i Out-Of-Service Well E Out-Of-Service Well Renewal a Cross-Connection Repair T New Pump T Pump Replacement IT Pump Repair n Raise Well Casing WELL CONSTRUCTION w Drilling Method CK-Mud l,Ro,'ttary.nlF1 Air Rotary n Auger n Cable Tool -1 Push Point n Other I~ Proposed Well Depth It Excavation in diameter Open Bottom L Gravel Pack/Gravel Size in diamete ^0- I Con ctor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel E Plastic 7 Stainless Steel J Other Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mix/7 gal water 9 ZIAI� Bentonite(20%solids) ❑Other gay, lAl Grout Placement Method umped -1 Free Fall 7 Other E Retardant/Accelerator(name) ROUIN COUN PEDESTAL Installed By i i Driller i Pump Contractor I Other L NMSN7-A J Concrete Pedestal El Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe �EpARTIuENT PUMP I Submersiblen Turbine n 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 R SIGNED �� TITLE /t- 'r DATE II /✓ IVSD 9 2018 TAL HEALTH 1*1ERVICES DEPARTMENT U E NLY / Application Accepted By Date Area v Employee ID# Grout Inspection By Date [J SPECIAL Well Permit Pump Inspection By Date [ I-1 WAIVER Received Soil Boring Inspection By Date u Constructed Well Depth ft COMMENTS 4fjA PE Sc Received he Amount Date Permit/ Invoice# Well ID# Codes Info Ca.h Remitted ` Service Request# 2. 4hc OFF 1 EHO 43-06 revised 4/14/18 ��D� WELL/PUMP PERMIT(((YYL Cad,- , 'y.a a