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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 { G CITY/ZIP m D g / CROSS STREET /` d C i� APN/'2j �/ PARCEL SIZE LAND USE APPLICATION# 0 OWNER NAME �//GV 1'O W h PHONE OWNER ADDRESS '' CITY/STATE/ZIP CONTRACTOR V,i �7 f 05.5 W e— S f �4 PHONE 3 Z 7 512 0 CONTRACTOR ADDRESS /�_ p 6.."_ 1 b S 7 CITY/STATE/ZIP--/ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 4C-57 u C-61 L D-09 L Other NUMBER ;5y F3/L 3 EXPIRATION DATE Z.OLO DOMESTIC WELL SAMPLING: I.1 General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)a Arsenic(4393) INTENDED USE 1-1 Domestic/Private I I Irrigation/Agricultural 11 Industrial (I Water Quality Monitoring I I Soil Sampling/Characterization L! Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I New Well ❑ Replacement Well I 1 Well Alteration/Modification 1_1 Other L! Monitoring Well(s) #of wells L i Soil Boring(s) #of borings ❑ Geotechnical #of borings I_i Out-Of-Service Vvell I1 Out-Of-Service Well Renewal I I Cross-Connection Repair LI New Pump XPumpReplacement I-1 Pump Repair I1 Raise Well Casing WELL CONSTRUCTION Drilling Method IL Mud Rotary L Air Rotary n Auger I 1 Cable Tool I I Push Point 1-1 Other Proposed Well Depth ft Excavation in diameter I I Open Bottom [I Gravel Pack/Gravel Size in diameter Li Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter '�5 in Thickness/Gauge/ASTM Sched LI Steel I I Plastic I I Stainless Steel i_1 Other Grout Seal Depth / 1)0 ft I_I Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement sack mix/7 gal water I I Bentonite(20%solids) L Other Grout Placement Method ❑ Pumped L Free Fall ii Other f I Retardant/Accelerator(name) PEDESTAL Installed By L Driller ❑ Pump Contractor I I Other 1 Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in I I Christy Box I I Stove Pipe PUMP ,Submersible I I Turbine I I Other HP/- T Pump Set--L2&—26 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 INSP,E/CT.I.OL—NS -PLEASE CALL (209) 953-7697 SIGNED� TITLE ®/CSrgY?�/ DATE 41—y—/ V PAY M' S N D p DQE ARTMENT SEI ONLY Application Accepted By Date Area Employee ID#V I % 1 � Grout Inspection By `1R Date 1 PECIAL Well Permit Pump Inspection By T \�f \& Dater\M 17M L I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS r PE Sc Received I V I, heck#/ Amount Permit] o e Info B Cash emitted Date S ryice Re uest# Invoice# Well ID# d C6 qSSS -I FT EHD 43-06 8/01/16 WELL/PUMP PERMIT