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• WELL/PUMP PERMIT AIA 1'430 30 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT ��,Q CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS l 3 IV coero I IGG ✓yi CITY/ZIP L'od Z�Q m m EI S '� 2 CROSS STREET APN V 1Y3 (�7- ' O L PARCEL SIZE() /�)�u LAND USE APPLICATION# o m OWNER NAME �[�(�A,,S/ L`� PHONE G� `-� r n (_o OWNER ADDRESS ��lb rc.zlA� o � CITY/STATE/ZIPUt �� ✓� {'�O(/— CONTRACTOR �Q�I(J0 2,170- A/jer_Cn t,,l�>�t0�iK�C'! (rerrc c. , PHONE 36Z ) J CONTRACTOR ADDRESS N I-j Vy i-/ CITY/STATE/ZIP L-4 C"4 /9'S Z1rD SUBCONTRACTOR ��Ale r/�f 'A be,-e PHONE 41/� SUBCONTRACTOR ADDRESS /Y( � CITY/STATE/ZIP /y/� LICENSE �C-57 CI C-61 1 D-09 ❑ Other NUMBER V C`0j ir EXPIRATION DATE DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) INTENDED USE [I Domestic/Private I I Irrigation/Agricultural I I Industrial ❑ Water Quality Monitoring n Soil Sampling/Characterization 11 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I I New Well 11 Replacement Well [I Well Alteration/Modification I I Other 1 1 Monitoring Well(s) #of wells Il Soil Boring(s) #of borings X Geotechnical Z #of borings I I Out-Of-Service Well I I Out-Of-Service Well Renewal I I Cross-Connection Repair !I New Pump I I Pump Replacement I I Pump Repair I1 Raise Well Casing WELL CONSTRUCTION Drilling Method i-1 Mud Rotary I1 Air Rotary ,(Auger ❑ Cable Tool F1 Push Point I I Other Proposed Well Depth I S ft Excavation & in diameter [i Open Bottom I I Gravel Pack/Gravel Size P jkmeter 1 Conductor Casing in diameter / Conductor Casing Depth ft Recie C ]' Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 11 Plastic ❑ Stainless Steel 111 Other Y Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) I 1 Sand Cement AADkryri' /7 g1 water I Bentonite(20%solids) I l Other oe UON Grout Placement Method 11 Pumped I I Free Fall Other ! ❑ Retardant/Accelerator(name) SOA PEDESTAL Installed By I I Driller n Pump Contractor i Other N06,Zr4TAL ❑ Concrete Pedestal IJ Dimensions:Width ft Length ft Thick in I.1 Christy Box ❑ PUMP I I Submersiblel I 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 J TITLE 5 f 5��I `hQ%ne&r DATE L D Ek ART MENT U QE, ONLY Application Accepted By Date Q Area Employee ID#� Grout Inspection By Date IJ SPECIAL Well Permit Pump Inspection By Date IJ WAIVER Received Soil Boring Inspection By Date 6 Constructed Well Depth ft COMMENTS PE Sc Received h Amount Permit/ Codes I B Cash e i e Date Service Request# Invoice# Well ID# 22 i EHD 43-06 6/01/16 WELL/PUMP PERMIT