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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 JOB ADDRESS �u� � 1 �Yl& A 1 CITY/ZIP 1 � � � � m 0 /� �^ D CROSS STREET W1 W A /LJ C/� CJS APN a-u In V �)-C _PARCEL SIZE �UID USE APPLICATION# A OWNER NAME 69 VAN I-` 4PYW V P 00 Pm- �(F� ' PHONE z OWNER ADDRESS -t2 r2w CITY/STATE/ZIP C �/ CONTRACTOR GL L Olt _A_ �P(H1ONEU I/ r(s CONTRACTOR ADDRESS \� �AJ r ITY/STATE/ZIP vd•t l •A SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/S /TAT E / ZIP LICENSE -57 L] C-61 C-61 D-09 ❑ Other NUMBER �'l.' ` EXPIRATION DATE DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) 1 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 ❑ Well Alteration/Modification ❑ Other ❑ 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 [7 Cable Tool ❑ Push Point ❑ Other Proposed Well Depth _eft Excavation U 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 Itleat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method El Pumped 11 Free Fall Other (�i FI 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 Cl 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 WORKE MPENSATION LAWS. MI IMUM 48 HOUR ANC NOT E REQUIRED FOR IN ECTIONS -PL SE CALL (2(09)(953(-76 7 SIGNED TITLE DATE` DF_ PA TMFNT USE ONLY Application Accepted By Date l — Area Employee ID#Adv Grout Inspection By Date EJ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS 4" �; PE SC Received eck Amount Permit/ Codes Info B ash Remitted Date Service Request# Invoice# R E"..0Si FI[ 22 6 I I-I 5-I W 2� 5 20 UIN COUNTY -- ENVIRONMENJAL HEAL – EHD 43-06 8/01/16 WELL/PUMP PERMIT