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WELL/PUMP PERMIT S JOAQU COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 N N-REF DABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED baJo ADORES Q CITYIZIP � Ar S J r� I / Irl a CRl 5$TRE �^'G APN ) ) _PARCEL SIZE �LAND USE APPLICATION# I ^ m 0 R NAME �L \ 1'AZM 7 /v�"' PHONE �r�/y U1 OWN DD S CITYISTATEIZIP.5 'j Q t-{�Ca-_J?1y�- CONTRACTOR 1`1��1 I /-� PHONE /L`'r� )�;}1 U)* —��J CONTRACTOR ADDRESS - l '/ �LL- CITY/STATE/ZJP O 0b r t/L1��1 I ,/A SUBCONTRACTOR • • r1 ""� PHONE �Ay, Al ~ �'yMV 7 I✓r CITYISTATE/ZIP PGl 1� C 3IJ 3 SUBCONTRACTOR ADDRESS � (- - '�^ LICENSE C-57 0 C-61 ❑D-09 ❑Other NUMBER O/S EXPIRATION DATE W DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural D Industrial ❑Water Quality Monitoring I 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 D Other ❑Monitoring Well(s) #of wells ❑Soll Borings) #of bodngs Geotechnical #of borings ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump 0 Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method 0 Mudoto 0 Air Rotary 0 Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth ft Excavation In diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter D Conductor Casing In diameter / Conductor Casing Depth It Well Casing Diameter_In Thickness/Gauge/ASTM Schad ❑Steel 0 Plastic D Stainless Steel ❑Other Grout Seal Depth It Id Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mixf7 gal water ❑Bentonite(20%solids) 0 Other Grout Placement Method jPumped 0 Free Fall ❑Other 0 Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other 0 Concrete Pedestal❑Dimenslons:Width It Length It Thick in ❑Christy Box 0 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. R ADVANCE NOTICE REQUIRED FOR INS TIQNS-PLEASE CALL(209)e53-7697 SIGNED TITLE N +`/5 DATE I ` Z r 9 A Aj INV TY r �fJ�1 �� DE A T M E N T SE ONLY Application Accepted By - - D to Area Employee ID# Grout Inspection By Date ❑ SPECIAL ell Permit ��"""" ' Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/Codes Info EICash emitted Date ervice Re nest# Invoice# Well ID# �. EHD43.06 rev&ed4114H8 WELL/PUMP PERMIT