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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 Ln &An ein l T/�.� �cm JOB ADDRESS U � J�nC Y � � CITY/ZIP m � v D CROSS STREETS h Aen(oc K IV,, W h7 APN `T IiIPARCEL SIZE �t ` 1 LAND USE APPLICATION# v m OWNER NAME PHONE �? OWNER ADDRESS Ij� CITY/STATE/ZIP CONTRACTOR T4-0_f'16 r) IY Q t l! 0• Ah j"/5 0 V► PHONE 20/7 - (3 6 7/—� 3201 CONTRACTOR ADDRESS3 V � L N tl hS 1��+� �A Y CITY/STATE/ZIP L-0�I /�/`I/ l SZ7 0 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS /CITLY/STATEE/)ZIP LICENSE C-57 11C-61 11D-09 L1 Other NUMBER b6 q(i V-/ EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural I I Industrial ❑ Water Quality Monitoring ASoil 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 ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth '2 Excavation �_ 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 I 1 Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) G Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall A Other —Tra✓h v"I-I? I I 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 ❑ 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 SIGNED ��(Jy1/ � 'l�/ TITLE l'��V�(JL7 / )� DATE it A QJ DEPARTMENT USE ONLY HEALTH DEPARTMENT Application Accepted By to t 2� Area ✓ Employee ID# IV-aAm Grout Inspection B Date Ll SPECIAL Well Permit Pump Inspection By Date 9 IJ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 2> 4 5 — ! P 0 om 1101:_2 zz s EHD 43-06 8/01/16 WELL/PUMP PERMIT