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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 yes T►'�c y / 95 3 d JOB ADDRESS l4y, � I CG' C�i� �'q ^ CITY/ZIP m \ /i APN � 11 PARCEL SIZE 1 / D CROSS STREET )y� ' L �'✓�N +� GLAND USE APPLICATION# m cn C NER NAME PHONE_ Gf'ER ADDRESS I CITY/STATE/ZIP q ` /� / CONTRACTOR �Z �r'c'1 C�l� /-I/VQ,1 I 0 If�,'yl e 1, or7 PHONE 2_0A 1/ �{3CEi �/� � •�/_70 GUNTRACTOR ADDRESS 102- h C in S��r� `�' 1 CITY/STATE/ZIP 1-(J��(I—A _``�2 7 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP { LICENSE /C-57 El C-61 [ID-09 ❑ Other NUMBER 6v `� - EXPIRATION DATE /3// -7 DOMESTIC WELL SAMPLING: iF, General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) ! Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial i-1 Water Quality Monitoring ❑ Soil 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 #of borings f bor ngs ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) Geotechnical 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal n Cross-Connection Repair I 11 New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION � � Drilling Method [I Mud Rotary [I Air Rotary f�l/Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth S - S 0 ft Excavation i h in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall [Other (-'M r7 1 e I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller I I Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible F1 Turbine H 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. �M'IINIMUpM48'H,Jn�UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TJ" 1 V TITLE 6"'JQ 5/S I DATE TVTIN ilQIJIY N MN LT DEPARTMENT USE ONLY CO7-r4 Application Accepted ByDate Z/ Area ` Employee ID# Crv1 Grout Inspection By 4C &=j_' Date ; _ LI SPECIAL Well Permit Pump Inspection By Date I i] WAIVER Received Soil Boring Ins ection By Date �2 Zf Constructed Well Depth ft COMMENTS PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Re 'tted Service Request# Li1 Z EHD 43-06 8/01/16 WELL/PUMP PERMIT