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L WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT C L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED o ��p JOB ADDRESS � m CROSS STREET a'L-fl'< APN PARCEL SIZE LAND USE APPLICATION#G� '] OWNER NAME / �/ PHONE L ( / OWNER ADDRESS �L/1' �. CITY/STATE/ZIP CONTRACTOR r IAC) pwa tL PHONE c3 3 t ��/ 0J0. -1 ,1 CONTRACTOR ADDRESS (,} CITY/STATE/ZIP � SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 CI C-61 11D-09 I I Other NUMBER 5`7 23eEXPIRATION DATE ®—L DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE Domestic/Private [] Irrigation/Agricultural ❑ Industrial F1 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 ❑ Monitoring Well(s) #of wells C I Soil Boring(s) #of borings [I Geotechnical #of borings ri Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ><New Pum -1 Pump Replacement n Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Metho6-41Mud Rotary ❑ Air Rotary [1 Auger [7 Cable Tool a Push Point ❑ Other Proposed Well Depth2�8 3 _ft Excavation i I-- in diameter []'Open Bottom 3'hlGravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched -'Z-00 U Steel 4"13lastic I Stainless Steel F1 Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) _*1Z and Cement sack mix/7 gal water ❑ Bento a(20%solids) ❑ Other Grout Placement Methoote Pumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By-.� Driller ❑ Pump Contractor ❑ Other 193 ❑ Concrete`¢e'd'estal []Dimensions:Width ft Length ft Thick in ❑ Christy Box Li Stove Pipe PUMP >tSubmersibleFl Turbine 11 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. MINIMUP424 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED TITLE tDW — DATE (, 1 1' bly AAKI -W JIIN W EV U TY T p p T qEP RTMENT USE ONLY , L 'n/h/� Application Accepted By Date Area '! Employee ID#Vim/ Grout Inspection By �'CZvL Date 7 g i 1 SPECIAL Well Permit Pump Inspection By AWN\3 Date ��L� �� 1-1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Amount Permit/ odes I o B Cas emitted Date Service Re uest# Invoice# Well ID# -I 0 ®a" cSi EHD 43-06 8/01/16 WELL/PUMP PERMIT